Technical-guide-to-HIV-prevention-treatmen
Technical Guide to HIV Prevention, Treatment and
Care for People Who Use Stimulants
CDARI Press March 2014
Contents
v
Explanatory notes
The following abbreviations are used in this Technical Guide :
ART
ATS
CDARI
STI
TB antiretroviral therapy amphetamine-type stimulants
Caribbean Drug and Alcohol Research Institute sexually transmitted infection
UNAIDS
UNFPA
UNDP
UNODC tuberculosis
Joint United Nations Programme on HIV/AIDS
United Nations Population Fund
WHO
United Nations Office on Drugs and Crime
World Health Organization
Genisis of this Technical Guide
A global technical meeting on stimulant drug use and HIV was held in São Paulo, Brazil, in January 2012. The meeting was organized by UNODC with the Government of Brazil (GoB) and included leading researchers and technical experts from countries affected by stimulant use and HIV. In addition to UNODC and the GoB representatives, participants included representatives of civil society, UNAIDS and UNDP. The meeting recommended a targeted approach to address the unique needs of certain sub -groups of stimulant drug users, especially those who also belong to other key populatio n groups such as sex workers and men who have sex with men, due to their increased risk of contracting HIV through high -risk sexual practices.
This draft of the Technical Guide is based on a global guidance document entitled “Technical guide to HIV prevention, treatment and care for stimulant users: discussion paper” which is in draft form and being finalized with further consultations with relevant stakeholders, including civil society organizations. This draft is based on a “final” draft of that global guidance written by Steve Shoptaw, approved by UNODC HIV Department and then further edited by Marcus Day.
Community Review
The final version edited by Marcus Day was then reviewed community stimulant experts from the community
Mat Soutwell and Mark Kinzy and the draft edited accordingly. That draft was then reviewed by LANPUD representative, Luiz Paulo Guanabara of Psicotropicus. In consultation with these key experts the Caribbean
Drug and Alcohol Research Institute is using this guidance to address HIV prevention for people who use coca based stimulants in the Caribbean and Latin America. This document is the product of that collaboration and contains no further input from the UN Family (UNODC, WHO or UNAIDS).
This Guide reflects the practical and needed interventions to mitigate the systemic harm caused by a criminalised environment of anti-drug laws and prohibitions. CDARI continues to support the development of a UN Technical Guide that will carry the endorsement by the UN Family. vi
I. Introduction
This Technical Guide describes a package of interventions with evidence of efficacy or - where in the absence of such data -, strong expert agreement that when implemented it will reduce barriers and enhance access to
HIV prevention, treatment and care for people who use stimulants. Further, it contains guidance and recommendations on methods for monitoring progress made in reducing HIV transmission among people who use stimulant drugs.
People who use stimulants, as defined in this Technical Guide , include individuals who use cocaine, various forms of smokeable cocaine base, commonly referred to as crack cocaine, paste or pasta base, paco , basuco: amphetamine-type stimulants (ATS) or any of the other varieties of psycho stimulant drugs.
There is a wide range of variability in levels of stimulant use, from minimal to occasional to regular/daily use.
People who use stimulant drugs differ in their range of responses: experience may vary from little or no consequences to various levels of distress, often compounded by other physical, mental or external factors that are exacerbated by the use of stimulants in a criminalised environment.
Factors determining the overlap between stimulant use and HIV transmission include three dimensions: the type of stimulant used; the way in which it is used and; contexts in which that use occurs. When providing access to HIV prevention, treatment and care to people who use stimulants, these dimensions require consideration:
• Types of stimulant drugs predominantly used (crack, cocaine, methamphetamine, methcathinone, ecstasy or other psychostimulants): HIV transmission risks among people who use stimulants vary by the type of drugs used and by whether risk behaviours occur in proximity to a local HIV epidemic.
• Route of administration and frequency of stimulant use: Stimulants are most commonly used via non-injection methods such as oral, smoked, snorted, or inserted anally. Short -acting stimulants like crack or powder cocaine are administered frequently whereas longer-acting stimulants such as amphetamine or methamphetamine tend to be used less frequently. A crucial variable appears to be the immediacy, duration and magnitude of the stimulants effect as well as the frequency and quantity of the stimulant used
1
. Vulnerability to HIV is heightened in certain contexts when stimulant use involves concomitant sexual behaviours.
• Unique subgroups and c ontexts in which stimulant are used: Some subgroups of stimulant users experience heightened vulnerability for the sexual transmission of HIV:, the homeless and other and street engaged populations, those with untreated, co -occurring psychiatric issues, men who have sex with men, sex workers, street youth, itinerant migrant labourers are examples of these subgroups. L ocal environmental factors (social, cultural, religious, economic, political) impact on and may create barriers to access to HIV prevention, treatment and care and require a sensitive, competent and sustained response in an environment where accessibility and utilisation of the service by people who use stimulants are a key indicator of success.
This technical guide fully embraces existing strategies and guidelines of the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Office on Dr ugs and Crime (UNODC) and the World Health
Organization (WHO) regarding HIV prevention, treatment and care for all persons, including for people who use drugs
2
,
3
,
4
. This Guide is intended for use by all stakeholders, service providers, policymakers and age ncies at the local, national or regional levels, who undertake to have a positive impact on HIV prevention, treatment and care among stimulant users.
1 Hatsukami DK, Fischman MW., 1996 Crack cocaine and cocaine hydrochloride. Are the differences myth or reality? JAMA 1996 Nov 20; 276(19):1580-8
2 Joint United Nations Programme on HIV/AIDS, Getting to Zero: 2011-2015 Strategy — Joint United Nations Programme on HIV/AIDS (UNAIDS) (Geneva, 2010). Available from www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2010/JC2034_UNAIDS_Strategy_en.pdf
3 WHO, UNODC, UNAIDS Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users (Geneva, World Health Organization,
2009). Available from www.who.int/hiv/pub/idu/idu_target_setting_guide.pdf
4 WHO, UNODC, UNAIDS Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users – 2012 Revision (Geneva, World Health
Organization, 2012). Available from http://apps.who.int/iris/bitstream/10665/77969/1/9789241504379_eng.pdf
World Drug Report 2012 (United Nations publication, Sales No. E.12.XI.1). Available from http://www.unodc.org/unodc/en/data-and-analysis/WDR-2012.html
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This Technical Guide provides:
A package of core health interventions for people who use stimulants, wh ose route of use is primarily through non-injecting means.
A framework and process for setting targets
A non exhaustive set of recommended indicators and targets (or “benchmarks”) for setting programme objectives and monitoring and evaluating outcomes of core health interventions for stimulant users
Examples of data sources
The needs of people who inject stimulants are critical as their vulnerability to HIV is possibly heighten due to the context in which their injecting takes place and their needs are al so addressed in this guide. This is decided due to the lack of available guidance on HIV prevention among people who inject stimulants.
In preparing this guide, it was evident that there is far less research globally addressing the prevention, treatment, and care of HIV among people who use stimulants regardless of the route of administration. The main body of research related to “drugs” and HIV tend to focus on the HIV vulnerability associated with the use of non-sterile syringes in the administration of an opioid. Most research specific to stimulant users describes findings from North America; fewer studies exist to advise interventions, whether prevention, treatment or care, from Africa, Asia, and South America. Throughout, references are given of peer reviewed, scientific rigorous evidence that support the recommendations. Where that level of evidence was unavailable or related but inconclusive, the Guide reverts to “promising practices” that are being utilised in a variety of resource environments and which in the opinions of experts, who work with people who use stimulant drugs, are worthy of inclusion for consideration and adaptation.
The importance of incorporating people who use stimulants into national targets for HIV prevention, treatment and care is underscored by the sheer size of the stimulant -using population worldwide, a diverse group of people second in size only to users of cannabis
5
.
People who use stimulants and engage in concurrent sexual behaviours have been shown to have a heigh tened vulnerability to HIV transmission and, for these individuals, reducing barriers to and facilitating access to core health interventions that have very limited availability globally despite the magnitude of the population size of stimulant users - is vital. Barriers that limit access and utilisation of services may or may not be relevant in all the varied contexts in which stimulants are used. Local needs assessments are key to the effective utilisation of the package of evidence-based interventions contained in this guide in a contextual and culturally appropriate manner. It is important to note that evidence of increased HIV transmissions linked to concurrent sexual behaviours may be noted in some, but not all of the subgroups that use stimulants, mak ing the need to utilise only those interventions appropriate to setting country-specific targets. For example, in the United States, attributable risk analyses among men who have sex with men show that non -injection substance use, particularly stimulant use, accounts for between 16
6
and 36 per cent
7
of HIV seroconversions; nevertheless, there is, as yet, no indication of a generalised HIV epidemic resulting from stimulant use in other sub populations in the U.S.
This Technical Guide is intended to be useful and adaptable for countries and communities with different levels of resources that are available to reducing the epidemic of HIV among those who use stimulant drugs. While the Guide focuses on people who use stimulants but do not inject as their prefer red route of administration, a significant minority of stimulant users do inject and, as such, targets involving HIV services for people who inject stimulants is considered valuable and therefore included. People who inject stimulants face two HIV transmission vectors:
the possible use of unsterilized syringes and injecting equipment
5 World Drug Report 2012 (United Nations publication, Sales No. E.12.XI.1). Available from http://www.unodc.org/unodc/en/data-and-analysis/WDR-2012.html
6 B. A. Koblin and others, “Risk factors for HIV infection among men who have sex with men”, AIDS, vol. 20, No. 5 (2006), pp. 731-739.
7 D. G. Ostrow and others, “Specific sex drug combinations contribute to the majority of recent HIV seroconversions among MSM in the MACS”, Journal of Acquired Immune Deficiency Syndromes, vol. 51, No. 3 (2009), pp. 349-355.
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and the possible heightened vulnerability to the sexual transmission of HIV attributed to the concurrent use of stimulants.
Setting targets involving HIV services for people who inject stimulants is briefly covered in the “Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users”
8
,
9
. What has been included here elaborates on that coverage and expands it t o ensure adequate detail is available in setting HIV service targets that include all people who use stimulants including those who inject.
This Technical Guide contains a variety of ways to set targets for monitoring the needs and progress of people who use psychostimulants to increase access to HIV prevention, treatment and care. At the same time, it is recognised that implementing interventions to reach such targets requires the political will of policymakers to acknowledge and integrate into the process the needs and concerns of people who use stimulants as an underserved group requiring attention. The following factors underscore the importance of including people who use stimulants in HIV/AIDS target-setting:
• HIV Treatment — since 1996, when antiretroviral therapy (ART) became accessible and more widely available, scientists and policymakers have debated whether and how to provide HIV treatment to individuals who use drugs, particularly those who use one or more psychostimulants. This debate init ially reflected concerns over the potential for development and transmission of medication -resistant strains of
HIV, the presumption being that methamphetamine -linked to poor ART adherence was inevitable
10
.This concern expanded to involve issues of social inequities and were voiced in such questions as: “ Are HIVinfected individuals who use stimulants worthy to merit an allotment of medication, especially in settings where the need for ART exceeds the supply available” or “ There is the concern that being on ART may correspond with increased risk behaviours” ie.: behavioural disinhibition. Neither of these questions are relevant to the public health whose focus is to apply resourses where the threat to the public health is the greatest.
• Prevention — using ART as part of combination HIV prevention strategy which may contain:
forms of non-occupational post-exposure prophylaxis
11
,
12
,
pre-exposure prophylaxis in men who have sex with men
13
,
14
,
HIV treatment as prevention in serodiscordant couples
15
and
vaginal microbicides
16
, to assist with the prevention of HIV acquisition.
Combination prevention approaches present ethical, moral and economic barriers as they are efficacious but require supplementary resources to be implemented
17
, and policymakers may be reluctant to allocate resources to a population of stimulant users that is criminalised, discriminated against and stigmatised.
There is a lack of data on ART adherence among the various subgroups of people who use stimulants.
8 WHO, UNODC, UNAIDS Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users (Geneva, World Health Organization,
2009). Available from www.who.int/hiv/pub/idu/idu_target_setting_guide.pdf
9 WHO, UNODC, UNAIDS Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users – 2012 Revision (Geneva, World Health
Organization, 2012). Available from http://apps.who.int/iris/bitstream/10665/77969/1/9789241504379_eng.pdf
10 R. J. Ellis and others, “Increased human immunodeficiency virus loads in active methamphetamine users are explained by reduced effectiveness of antiretroviral therapy”, Journal of Infectious
Diseases, vol. 188, No. 12 (2003), pp. 1820-1826
11 M. Schechter and others, “Behavioral impact, acceptability, and HIV incidence among homosexual men with access to postexposure chemoprophylaxis for HIV”, Journal of Acquired Immune
Deficiency Syndromes, vol. 35, No. 5 (2004), pp. 519-525
12 D. Smith and others, “Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S.
Department of Health and Human Services”, Morbidity and Mortality Weekly Report, Recommendations and Reports, vol. 54, No. RR-2 (2005), pp. 1-20. Available from www.cdc.gov/mmwr/PDF/rr/rr5402.pdf
13 R. M. Grant and others, “Preexposure chemoprophylaxis for HIV prevention in men who have sex with men”, New England Journal of Medicine, vol. 363, No. 27 (2010), pp. 2587-2599
14 United States of America, Department of Health and Human Services, Centers for Disease Control and Prevention, “Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men”, Morbidity and Mortality Weekly Report, vol. 60, No. 3 (2011). Available from www.cdc.gov/mmwr/pdf/wk/mm6003.pdf
15 M. S. Cohen and others, “Prevention of HIV-1 infection with early antiretroviral therapy,” New England Journal of Medicine, vol. 365, No. 6 (2011), pp. 493-505
16 Q. Abdool Karim and others, “Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women”, Science, vol. 329, No. 5996 (2010), pp. 1168-1174
17 P. Lurie and others, “Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations”, Journal of the American Medical Association, vol. 280, No. 20 (1998), pp. 1769-1773
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• Care — People with HIV (PWHIV) who use illicit stimulants may face situations that interfere with their ability to gain access to and make use of ART. These situations, loosely referred to as challenges to creating an enabling environment include:
housing instability or homelessness;
stigma (barriers in access, limited access to or being placed on, a sub -optimal regimen of ART); gender dynamics (stigma from “role abandonment”, sexism, complications from pregnancies and child-rearing obligations for women who use stimulants; stigma fro m homosexuality for men and transgendered populations);
being in prison or other closed settings where there is no commitment to addressing these contexts as part of the overall public health. (difficulties of ensuring that stimulant users in prisons and other closed settings have access to HIV services and a comprehensive set of components of care to draw upon).
• Lack of models — a technical guide that contained targets for countries with regard to universal access to HIV treatment, prevention and care for people who inject drugs was first published in 2009 and revised in 2012 by WHO, UNODC, and UNAIDS. This document broke new ground in recognising the need to set targets for people who inject drugs; however, key differences exist between people who inject opioids and people who inject stimulants, complicating efforts to adapt an omnibus model of prevention based primarily on opioid pharmacotherapy and sterile syringe distribution. OST as a cornerstone intervention to address illicit opioid injecting is less effective in addressing issues for people who inject a mixture of stimulants and opioids.
How stimulants are used is key to determining the efficiency in which brain reacts to their pleasurable effects and therefore understanding the dynamics for what is described as a compulsivity of use.
18 This obsessive chasing pleasure is one key element to understanding the transmission dynamics that present with the concurrence of stimulant use and sexual behaviours in an HIV incidence rich environment .
Further clouding the issue is the vast majority of people who use stimulants prefer a non -injecting route of administration making access to existing drugs services that focus on opioid based syringe services less than ideal, as a first point of contact when accessing services.
An additional confounder is the proliferation of practices common in some regions for the quick preparation of liquids containing methcathinone or methamphetamine “on the street”, which carry the yet to be studied potential for severe health dangers, owing to the use of uncontrolled adulterants in the production process.
Evidence exists that clearly show that concurrent stimulant use and sexual behaviours has been identified in certain key population such as men who have sex with m en, street youth, itinerant labourers and sex workers. The risk of HIV transmission among stimulant users can vary depending upon factors that include local HIV prevalence and incidence in specific groups. Stimulants have functional attributes that help some users to inhibit appetite, remain awake at night, work for long hours, facilitate sexual arousal, or fund stimulant purchases by generating an income via sex work. These are important contextual factors related to stimulant use that may diminish positiv e treatment outcomes of planned interventions if they are ignored.
There is no consensus in the literature to guide the selection of targets, for example concerning drug use behaviours and sexual behaviours concomitant with drug use to ensure access to HIV prevention, treatment and care among stimulant users. Potential targets and indicators included in this document were adapted from those in the technical guide for injection drug users. The field testing of these indicators is recommended to advise their feasibility and applicability to cultural and contextual setting in which they are applied. Feed back on the efficacy is invited and may be sent to: cdari@candw.lc
.
II. Background
A. HIV risk among people who use cocaine
18 Verebey, K., & Gold, M. S. From coca leaves to crack: The effects of dose and routes of administration in abuse liability. Psychiatric Annals, 1988 18(9), 513-520.
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In 2010, the World Drug Report claimed that an annual prevalence of cocaine use, including smokeable cocaine, was estimated at between 0.3 per cent and 0.4 percent of the world’s population aged 15 -64, corresponding to between 13.2 to 19.5 million people. The largest national consumer of cocaine and crack is the United States, followed closely by West and Central Europe. By contrast, cocaine use in Eastern Europe remains limited. Cocaine is often trafficked through the Caribbean and West Africa, and there is a notable prevalence of its use that follow the transit routes through the Caribbean, and in West Africa along the transport routes to South Africa, Australia and New Zealand. High prevalence of the use smokable cocaine also exists in
South American countries, especially in Argentine, Brazil and Colombia,.
People who use cocaine and crack share important characteristics. Smoking cocaine correlates with sexually transmitted infections (STIs) such as HIV and syphilis
19
.
20
,
21
,
22
. Research has also indicated that HIV/STI acquisition is increased when cocaine or crack is co-administered with heroin
23
. Certain sub populations of male and female cocaine and crack users report an increased libidinous urge, corresponding with high numbers of reported sexual partners and episodic unprotected sex
24
.
The desire to acquire smokable cocaine triggers disinhibition and, as such, it is often found in the context of sexual behaviours such as the exchange of sex for drugs or money. There are indications of the immuno depressiveness of crack and cocaine and that its use may impede the mechanisms that inhibit viral uptake and may enhance viral progression. There is evidence that cocaine and crack use accelerates HIV disease progression, particularly among women living with HIV
25
, although the mechanism for this is still unclear.
PWHIV who smoke cocaine have been shown to be less likely than their non -cocaine-smoking peers to access medical services and are more likely to have lower rates of ART adherence
26
. There are barriers that impede the promotion of an enhancing environment to increase utilisation of services. The main challenge has been the provision of HIV and other health care services to a highly criminalised, demonised, stigmatised and discriminated population.
B. HIV risk among users of amphetamine-type stimulants (ATS)
In 2010 the World Drug Report claimed an worldwide prevalence of ATS use estimated between 0.3 and 1.2 per cent of the world’s population aged 15-64, corresponding to between 14.3 to 52.5 million people. Further, the prevalence of ecstasy use was estimated between 0.2 and 0.6 per cent of the world’s population, corresponding to 10.5 to 28.1 million people, making this class of drugs the most -used illicit substance in the world after cannabis. Currently, there is evidence of ATS use i n Africa, North America, East and South-East
Asia, New Zealand, Australia and some parts of Europe.
People who use and inject ATS in non-sterile settings using non-sterile and pre-used syringes are at the same risk of drug-related HIV transmission as people who inject opioids under the same conditions. The literature has also identified the co-occurrence of ATS use with unprotected sexual behaviours as a major issue to consider when planning targets to eliminate HIV transmission. It’s the same dynamics as cocaine and smokable cocaine as reported above. Methamphetamine and other ATS tend to be inexpensive and have long half -lives.
In addition to creating euphoria, ATS also have a strong functional profile, including sharpening attention, brightening mood, enhancing libido, building stamina and dampening appetites for food and water.
Many users seek out ATS to combat fatigue, especially long-haul truck drivers (e.g. in India and South Africa).
ATS use has been reported by members of key populations at high risk of HIV transmission, such as female sex workers and men who have sex with men. The use of ATS has been reported to facilitate particular sexual
19 R. Marx and others, “Crack, sex, and STD”, Sexually Transmitted Diseases, vol. 18, No. 2 (1991), pp. 92-101
20 M. L. Williams and others, “An assessment of the risks of syphilis and HIV infection among a sample of not-in-treatment drug users in Houston, Texas”, AIDS Care, vol. 8, No. 6 (1996), pp. 671-682
21 M. W. Ross and others, “Sexual behaviour, STDs and drug use in a crack house population”, International Journal of STD and AIDS, vol. 10, No. 4 (1999), pp. 224-230
22 M. L. Williams and others, “Determinants of condom use among African Americans who smoke crack cocaine”, Culture, Health and Sexuality, vol. 2, No. 1 (2000), pp. 15-32
23 M. W. Ross and M. L. Williams, “Sexual behavior and illicit drug use”, Annual Review of Sex Research, vol. 12, 2001, pp. 290-310
24 M. W. Ross and others, “Sexual risk behaviours and STIs in drug abuse treatment populations whose drug of choice is crack cocaine”, International Journal of STD and AIDS, vol. 13, No. 11 (2002), pp. 769-774
25 J. A. Cook and others, “Crack cocaine, disease progression, and mortality in a multicenter cohort of HIV-1 positive women”, AIDS, vol. 22, No. 11 (2008), pp. 1355-1363
26 M. K. Baum and others, “Crack-cocaine use accelerates HIV disease progression in a cohort of HIV-positive drug users”, Journal of Acquired Immune Deficiency Syndromes, vol. 50, No. 1 (2009), pp.
93-99
5
behaviours and males have reported that it enhances stamina. Smoking is a common route of administration
27
.
PWHIV who are regular methamphetamine users show measurable negative effects on neuropsychological functioning
28
over an above the negative effects caused by HIV and hepatitis C
29
. Methamphetamine use significantly elevates the biological vulnerability to H IV infection
30
and increases HIV disease progression
31
,
32
.
While these findings are drawn from research conducted among men who have sex with men (MSM) and while directly relevant to this group, they are not without interest when setting more general targets for stimulant users, as the biological vulnerabilities are more than likely generalisable to all humans who use stimulants.
III. Interventions for HIV prevention, treatment and care for people who use stimulants
This Guide describes how evidence-based and recommended interventions may be helpful to stimulant users as a group whose primary risk of HIV transmission is through sexual behaviours correlated to their stimulant use.
A comprehensive package of efficacious interventions for HIV prevention, trea tment and care among stimulant users (who are mostly non-injecting) include:
1.
HIV testing and counselling
2.
Antiretroviral therapy (ART)
3.
Needle and syringe programmes for people who inject stimulants
4.
Harm reduction services targeting stimulant use and other evidence-based drug dependence treatment.
5.
Condom programmes for people who use stimulants and for their sexual partners
6.
Screening, prevention and treatment of STIs, hepatitis B, hepatitis C, and tuberculosis (TB)
7.
Behavioural interventions aimed at reducing HIV transmission
8.
Targeted information, education and communication programmes
Inclusion criteria for this comprehensive list of interventions
An extensive literature search as well as consultation with experts from around the world w ere conducted to develop this comprehensive list of interventions. The literature search included randomized controlled trials of
HIV interventions targeting people who use cocaine, smokable cocaine, methamphetamine, and or other ATS.
Other studies were also considered if they included a comparison arm comprising of people who used ATS and met the same inclusion criteria for single population studies. Details of the search method are described in
Annex I. Given the limited number of randomized clinical trials eva luating HIV interventions for stimulantusing populations and the purpose of the document to facilitate access to HIV prevention, treatment and care for stimulant users, other interventions that have been shown to be efficacious were considered. Although t he applicability of such interventions have not been studied specifically among people who use stimulants, there exists no evidence to suggest that stimulant users should be excluded from receiving these interventions or that these interventions would not be effective if applied appropriately and with the necessary population centred support. It is the position of this Guide that these interventions may be considered appropriate in the prevention, treatment, and care for HIV among stimulant users.
A comprehensive approach is necessary to be successful in addressing HIV epidemic among people who use stimulants. All eight interventions addressed in this Guide may be considered for use if found to be contextual and cultural appropriate. Stakeholders can utilise epidemiologic data of the local epidemic and the unique characteristics of the “setting” and available resources to make a final determination of which interventions are appropriate to put on offer. It is advantageous that this final set be considered as components of a
27 Australia, National Drug and Alcohol Research Centre, National Drug and Alcohol Research Centre: 2007 Annual Report (Sydney, University of New South Wales, 2007). Available from http://ndarc.med.unsw.edu.au/sites/ndarc.cms.med.unsw.edu.au/files/ndarc/resources/2007%2BANNUAL%2BREPORT.pdf
28 J.C. Scott and others, “Neurocognitive effects of methamphetamine: a critical review and meta-analysis”, Neuropsychology Review, vol. 17, No. 3 (2007), pp. 275-97
29 M. Cherner and others, “Hepatitis C augments cognitive deficits associated with HIV infection and methamphetamine”, Neurology, vol. 64, No. 8 (2005), pp. 1343-1347
30 M. W. Plankey and others, “The relationship between methamphetamine and popper use and risk of HIV seroconversion in the multicenter AIDS cohort study”, Journal of Acquired Immune
Deficiency Syndromes, vol. 45, No. 1 (2007), pp. 85-92
31 L. Chang and others, “Additive effects of HIV and chronic methamphetamine use on brain metabolite abnormalities”, American Journal of Psychiatry, vol. 162, No. 2 (2005), pp. 361-369
32 M. J. Taylor and others, “Effects of human immunodeficiency virus and methamphetamine on cerebral metabolites measured with magnetic resonance spectroscopy”, Journal of NeuroVirology, vol.
13, No. 2 (2007), pp. 150-159
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- 7 - comprehensive package, offered and delivered in combination, not in isolation . It is important to take into account the setting or context in which stimulant use overlaps with sexual behaviours that increase vulnerability to HIV transmission, when considering the range of interventions that address stimulant use and
HIV.
The comprehensive package includes HIV prevention interventions that have been demonstrated to be effective when used by the general population, such as HIV testing an d counselling, provision of ART, utilisation of harm reduction programmes addressing the needs of people who use stimulants , and condom distribution programmes. Where evidence specific to people who use drugs existed such as the efficacy of sterile syringe distribution in reducing HIV, this has also been included here and crafted specifically to a stimulant user environment.
The lack of approved pharmacotherapies hampers HIV prevention
The second intervention listed in the Technical Guide for Injecting Drug Use –what guide, where is
“ Opioid substitution therapy (OST) and other evidence-based drug dependence treatment”.
There is a preponderance of data that unequivocally shows that the proper dosing of OST greatly reduced syringe use as a route of administration of the opioids. This has been shown effective in reducing syringe use and therefore reducing the chance of HIV transmission by the sharing of non -sterile syringes and other injecting equipment.
OST has the added positive health outcome of transitio ning service user from illicit, potentially harmful street drugs on to pharmaceutical quality substitutes. The inclusion of “other evidence -based drug dependence treatment” was a challenge in this Guide. The purpose of this Guide is the prevention of HIV i n people who use stimulants. While drug dependence treatment opportunities may be a welcome respite from heavy episodic stimulant use, abstinence based drug treatment has been shown to be ineffective in addressing HIV transmission among the population of stimulant users.
In the absence of acceptance of pharmacotherapies, it is a challenge to include drug dependence treatment for people who use stimulants as it has not shown any evidence of being effective in reducing HIV transmission.
Therefore the decision was taken to name the 4 th intervention in this Guide “Harm reduction services targeting non-injecting stimulant use and other evidence-based drug dependence treatment”. The emphasis is on the provision of low threshold, harm reduction services with th e same caveat regarding the ineffectiveness of
“other evidence-based drug dependence treatment” in the prevention of HIV transmission. (Self-help groups like Narcotic Anonymous tend not to be considered evidence -based, although they might point a direction to what other drug dependence treatments could be.)
Interventions in the comprehensive package are to be offered voluntarily, be culturally sensitive, gender and age appropriate and non-discriminatory. UNAIDS has published “ Practical Guidelines for Intensifying HIV
Prevention”
33
, which includes a list of key questions developed to assist countries in undertaking local assessments of their epidemic. The Guidelines also provides information on planning an effective national HIV response.
1. HIV testing and counselling
More than 60 per cent of people living with HIV worldwide are unaware of their HIV status
34
. Knowledge of
HIV status remains a crucial first step to guiding prevention, treatment, care and support services. Guidance documents for countries have been produced on provider-initiated testing and counselling
35
,
36
that recommend that HIV testing be closely linked to prevention, treatment, care and support services. Stimulant users may be unaware of their HIV status owing to the non-utilisation or unavailability of testing opportunities. This underscores the importance of HIV testing that is free, assessable, voluntary, consented to, confidential and
33 Joint United Nations Programme on HIV/AIDS, Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access (Geneva, 2007). Available from http://data.unaids.org/pub/Manual/2007/20070306_prevention_guidelines_towards_universal_access_en.pdf
34 Joint United Nations Programme on HIV/AIDS, UNAIDS World AIDS Day Report 2011 (Geneva, 2011). Available from www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/JC2216_WorldAIDSday_report_2011_en.pdf
35 World Health Organization and Joint United Nations Programme on HIV/AIDS, Guidance on Provider-Initiated HIV Testing and Counseling in Health Facilities (Geneva, 2007). Available from www.who.int/hiv/pub/guidelines/9789241595568_en.pdf
36 World Health Organization and United Nations Office on Drugs and Crime, Guidance on Testing and Counselling for HIV in Settings Attended by People Who Inject Drugs: Improving Access to
Treatment, Care and Prevention (Geneva, 2009). Available from www.who.int/hiv/topics/idu/care/GuidanceTC_IDUsettings.pdf
7
includes counselling and referral services. Community based “rapid -testing” procedures for HIV testing and counselling reduce barriers to knowing ones HIV status and help avoid the challenge of people not returning to the clinic to receive their test results. “Op out” services must be voluntary and consent given not implied.
Additional guidance on HIV testing and counselling developed by WHO are available for a more in -depth understanding
37
,
38
.
2. Antiretroviral therapy
Antiretroviral therapy has been shown to suppress viral load, slow the progression of HIV disease and reduce
HIV-related morbidity and mortality
39
,
40
,
41
. Although over 14.2 million people were in need of ART in 2009, only 6.6 million people in low-and middle-income countries had access to it at the end of 2010 ( UNAIDS World
AIDS Day Report 2011 ). There is excellent evidence that cannabinoids found in cannabis suppresses HIV progression in treatment naive
42
PWHIV. Cannabis use could be promoted as pre-cursor to ART for those individuals who are waiting to commence ART
43
.
Antiretroviral therapy for disease management in PWHIV stimulant users
PWHIV stimulant users benefit from coordinated services that address both the biomedical and psychosocial issues common to people who use drugs. The priority is providing the additional attention needed to ensure access and utilisation of ART, and to regimens that boost medication adherence and retention in care
44
,
45
,
46
,
47
.
The benefits of ART are clear and well documented. For example PWHIV cocaine users have been shown to have accelerated HIV disease progression
48
and mortality
49
, yet the immune-enhancing effects of consistent
ART adherence are far greater than negative immune effects caused by stimulant use
50
,
51
.
For HIV-infected pregnant women, initiation of ART or antiretroviral prophylaxis during pregnancy, delivery and breastfeeding is recommended by WHO
52
,
53
,
54
to reduce mother-to-child transmission of HIV. As stimulantusing women living with HIV who are mothers or are pregnant face stigma as well as serious physical, social and economic challenges, methods and resources for ensuring access and utilisation to these medications as part of the prevention of mother-to-child transmission programme is vital.
37 World Health Organization, A handbook for improving HIV testing and counselling services: field-test version. (Geneva, 2010). Available from http://www.who.int/hiv/pub/vct/9789241500463/en/index.html
38 World Health Organization, Delivering HIV test results and messages for re-testing and counselling in adults. (Geneva, 2010). Available from http://www.who.int/hiv/pub/vct/hiv_re_testing/en/index.html
39 .F. J. Palella, Jr., and others, “Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection”, New England Journal of Medicine, vol. 338, No. 13 (1998), pp. 853-860
40 R. S. Hogg and others, “Improved survival among HIV-infected patients after initiation of triple-drug antiretroviral regimens”, Canadian Medical Association Journal, vol. 160, No. 5 (1999), pp. 659-
665
41 C. Lavalle and others, “Reduction in hospitalization costs, morbidity, disability, and mortality in patients with AIDS treated with protease inhibitors”, Archives of Medical Research, vol. 31, No. 5
(2000), pp. 515-519
42
Treatment naive paitents are those who have yet to initiate anti -retro treatment for HIV.
43 Costantino CM, Gupta A, Yewdall AW, Dale BM, Devi LA, et al. (2012) Cannabinoid Receptor 2-Mediated Attenuation of CXCR4-Tropic HIV Infection in Primary CD4+ T Cells. PLoS ONE 7(3): e33961. doi:10.1371/journal.pone.0033961
44 J. H. Arnsten and others, “Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users”, Journal of General Internal Medicine, vol. 17, No. 5 (2002), pp. 377-381
45 K. Ingersoll, “The impact of psychiatric symptoms, drug use, and medication regimen on non-adherence to HIV treatment”, AIDS Care, vol. 16, No. 2 (2004), pp. 199-211
46 G. M. Lucas and others, “Adherence, drug use, and treatment failure in a methadone-clinic-based program of directly administered antiretroviral therapy”, AIDS Patient Care and STDs, vol. 21, No. 8
(2007), pp. 564-574
47 G. M. Lucas, C. W. Flexner and R. D. Moore, “Directly administered antiretroviral therapy in the treatment of HIV infection: benefit or burden?”, AIDS Patient Care and STDs, vol. 16, No. 11 (2002), pp. 527-535
48 Baum (2009)
49 Cook (2008)
50 Ellis 2003
51 S. Shoptaw and others, “Cumulative exposure to stimulants and immune function outcomes among and HIV-negative men in the Multicenter AIDS Cohort Study”, International Journal of STD &
AIDS, vol. 23, No. 8 (2012), pp. 576-80
52 World Health Organization, Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Recommendations for a Public Health Approach (Geneva, 2010). Available from http://whqlibdoc.who.int/publications/2010/9789241599818_eng.pdf
53 World Health Organization, “Kesho Bora study: preventing mother-to-child transmission of HIV during breastfeeding — policy brief”, document WHO/RHR/11.01. Available from www.who.int/reproductivehealth/publications/rtis/KeshoBora_study.pdf
8
- 9 -
Aggressive management of infectious co-morbidities also has benefits for stimulant users. This intervention ensures that PWHIV who use stimulants are screened for hepatitis B and C infection prior to initiation of ART.
The presence of HIV infection and co-occuring stimulant use is not a contraindication to treatment of acute
HCV infection. With HIV/HCV-coinfected patients, as with HCV-monoinfected patients, early treatment of acute HCV infection yields a much higher rate of sustained virological response (SVR) than does treatment of chronic HCV infection.
55
PWHIV stimulant users with hepatitis B co -infection should have access to safe and effective treatments for both diseases as described in current guidelines
56
,
57
.
PWHIV stimulant users who have access to, receive and effectively utilise ART will see improvements in their immune system function, which is likely to provide comparable levels of protection against TB co-infection to those PWHIV who do not use stimulants. This benefit is greatest in countries in which TB is endemic [50].
Advancements in simplified regimens
58
for the treatment of latent TB, involving once -weekly combination medication, address some concerns over TB adherence problems with stimulant users. The cost of the therapies and the drug interactions with ART may still present barriers to accessing effective TB treatment in some settings. Additional treatment guidelines are described in chapter 5 of HIV/AIDS Treatment and Care: Clinical
Protocols for the WHO European Region
59
.
There are no serious medical concerns that would preclude providing ART to stimulant users. Cocaine is metabolized in a minor pathway via CYP 3A4
60
, which presents few possibilities for drug interactions or hepatotoxicity. There are no data describing pharmacologic interactions between cocaine and ART.
Metabolism of ATS is mainly through CYP 2D6. Protease inhibitors, such as ritonavir are inhibiting agents that decrease the activity of liver enzymes, thus decreasing metabolism and thus increasing the serum concentration of, in this case, amphetamines. This higher concentration of amphetamine could lead to increased toxicity (i.e. “boosted methamphetamine”). PWHIV amphetamine users who are being prepared for initiation of ART should be informed of this effect and recommend ed that if they select to continue using amphetamines,
, they should reduce their usual dose by 1/3 until they are sure of the effect , in order to avoid overdose risk.
After nearly 20 years of surveillance only one death
61
has been noted of an PWHIV who used ecstasy while on protease inhibitors.
Antiretroviral therapy as prevention for people who use stimulants
Using ART as a part of combination HIV preventio n is efficacious for preventing HIV transmission in heterosexual serodiscordant couples (early treatment as prevention)
62
. The data is clear that PWHIV relatively adherent to their ART have greatly reduced “infectivity”, thus rolling out treatment may be pe rceived as being for the benefit of the community. Care should be taken to stress at every opportunity that the application of universal access and the resources applied are for the benefit of the patient and their health outcome. Any community benefit in terms of reduced incidence are a bonus to be enjoyed but not justification for mandatory treatment.
The provision of ATZ to health care workers to prevent HIV transmission
63
, after an occupational exposure such as a needle stick injury, dramatically decr eased the incidence of seroconversion among health workers
54 World Health Organization, “PMTCT strategic vision 2010-2015: preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals” (Geneva, 2010).
Available from www.who.int/hiv/pub/mtct/strategic_vision.pdf
55 Fox, R., Hepatitis C Infection, January 2011, accessed 21 March 2014, found at http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-616_hepatitis_c.html
56 United States of America, Department of Health and Human Services, Panel on Antiretroviral Guidelines for Adults and Adolescents, Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected
Adults and Adolescents (2011). Available from www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf
57 “Management of hepatitis B and HIV coinfection”, in HIV/AIDS Treatment and Care: Clinical Protocols for the WHO European Region, (Copenhagen, World Health Organization Regional Office for
Europe, 2011). Available from http://www.euro.who.int/__data/assets/pdf_file/0011/152012/e95792.pdf
58 United States, Department of Health and Human Services, Centers for Disease Control and Prevention, “TB elimination: treatment options for latent tuberculosis infection” (Atlanta, 2011). Available from www.cdc.gov/tb/publications/factsheets/treatment/LTBItreatmentoptions.pdf
59 “HIV/AIDS treatment and care for injecting drug users”, in HIV/AIDS Treatment and Care: Clinical Protocols for the WHO European Region, I. Eramova, S. Matic and M. Munz, eds. (Copenhagen,
World Health Organization Regional Office for Europe, 2007). Available from www.euro.who.int/__data/assets/pdf_file/0009/78138/E90840_Chapter_5.pdf
60 P. Pellinen and others, “Cocaine N-demethylation and the metabolism-related hepatotoxicity can be prevented by cytochrome P450 3A inhibitors”, European Journal of Pharmacology, vol. 270, No. 1
(1994), pp. 35-43
61 B. Mirken, “Danger: possibly fatal interactions between ritonavir and ‘ecstasy’, some other psychoactive drugs”, AIDS Treatment News, No. 265, 1997, p. 5
62 Cohen 2011
63 This came to be refered to as: post exposure prophylaxis
9
when done under certain conditions.
64
This post event protective intervention was latter applied in cases of non-occupational exposure such as rape, cases of unprotected sex with an anonymous partne rs, condom breakage, sharing a syringe for injection drug use 65 and for helping HIV-uninfected men who have sex with men remain uninfected (pre-exposure prophylaxis)
66
.
While stimulant users are a group that may benefit disproportionately from combination HIV prevention strategies by reducing the pool of PWHIV with high viral load in their sexual networks, they have been excluded from “proof-of-concept” and early efficacy clinical trials. This exclusion ensures interventions that lack evidence will persist due to insufficient data in which to make informed decisions.
Still, these approaches warrants consideration, particularly in countries in which stimulant use can be shown to be an independent factor accounting for new HIV transmissions.
Further guidance and information on ART are available from WHO and the United States Department of
Health and Human Services.
3. Needle and syringe programmes for people who inject stimulants
For people who inject stimulants, sterile syringe distribution programmes will help reduce HIV transmission risks. Harm reduction strategies that address structural barriers for people who use stimulants and are at high risk of HIV are needed to increase utilisation of treatment and prevention services that support a reduction i n
HIV transmission. In addition to organisational sterile syringe programmes, reliance on peer outreach, peer -topeer support efforts as well as support for sterile syringe distribution and secondary distribution via user networks and other alternative, informal vehicles are appropriate strategies to increase service accessability.
The frequency and pattern of injection may vary substantially among people who inject stimulants and a context or setting-based approach should be considered when designing programmes for this population.
Stimulant Injecting and NSP/OST programmes
It is suggested that those individuals and organisations working in areas in which stimulant injecting is evident refer to the “Technical guide for countries to set targets for univers al access to HIV prevention, treatment and care for injecting drug users”. Care and thought need to be exercised when contemplating the integration of people who inject stimulants into existing syringe programmes designed for HIV prevention among people wh o inject opioids. Programmes whose objective is to reduce the frequency of injecting by the provision of opioid assisted therapy present an imperceptible yet none the less, tangible barrier for people who use stimulants. OST is not an appropriate treatment for stimulant use and as stated there is NO currently approved or accepted pharmacotherapies for stimulant users. The trajectory of an NSP/OST programme that supports the transit of people from injecting to orally administered OST leaves stimulant users w ith no comparable, accepted substitute and this may create a barrier to integration in the programme.
4. Harm reduction services targeting non-injecting stimulant use and other evidencebased drug dependence treatment.
In this Guide, harm reduction services are defined as any intervention aimed at reducing the harms associated with substance use, inclusive of pharmacological, behavioural, or a combination of these approaches. As stated above one challenge to the applicability of this intervention for pe ople who use stimulants is the lack of accepted, approved pharmacotherapies.
In the context of internationally accepted norms, “other evidenced based drug dependence treatment” does not include compulsory treatments delivered in detention settings as they are not efficacious for treating drug
64 Katz, M. H.; Gerberding, J. L. (1997). "Postexposure Treatment of People Exposed to the Human Immunodeficiency Virus through Sexual Contact or Injection-Drug Use". New England Journal of
Medicine 336 (15): 1097–1100. doi:10.1056/NEJM199704103361512. PMID 9091810
65 Cardo, D. M.; Culver, D. H.; Ciesielski, C. A.; Srivastava, P. U.; Marcus, R.; Abiteboul, D.; Heptonstall, J.; Ippolito, G. et al. (1997). "A Case–Control Study of HIV Seroconversion in Health Care
Workers after Percutaneous Exposure". New England Journal of Medicine 337 (21): 1485–1490. doi:10.1056/NEJM199711203372101. PMID 9366579
66 Grant 2010
10
- 11 - dependence or HIV and are not consistent with international human rights standards. Abstinence based drug dependence treatment has been shown to be ineffective as a method for reducing HIV transmission in stimulant users.
Additional or alternative harm-reduction services may be needed to meet the needs of people who use stimulants. This includes access to mechanical HIV prevention strategies such as the distribution of new smoking apparatus for use with smokeable sti mulants, non-heat conducting tips to be placed on metal and glass stems to reduce lip burns and resulting blisters, filters, lip balm and smoking foil
67
and straws for snorting.
While there is promising data supporting the distribution of straws to reduce t ransmission of hepatitis C, their overall efficacy for minimising the transmission risks for HIV remains unclear. For a service looking to attract people who use drugs, the distribution of these items often serve as an incentive in engaging people who use stimulants.
Evidence of the effectiveness of harm reduction services is most compelling in drug injecting dependence, where individuals who receive low threshold, harm reduction services such as opioid substitution therapy and needle syringe programs have been shown to have reduced HIV transmissions
68
. Effective alone, harm reduction programmes combined with the provision of ART creates a comprehensive response for people who use drugs.
Organisations that are implementing “promising practices” by applyin g a harm reduction “philosophy” to a non-injecting stimulant environment have the opportunity to share their experiences with others in an effort to develop innovative interventions that address the needs of this little studied community.
Some people who use stimulants in highly criminalised environments face challenges associated with poverty, unemployment, unstable housing and incarceration. Harm -reduction programmes that address these issues and offer meals, shower facilities, housing, legal assistance and other basic services may help stimulant users in need to stabilise their living situation, which can increase their access to services related to HIV and other co morbidities, improve adherence to medication schedules and help them maintain ongoing HI V care.
Pharmacotherapies
Pharmacotherapies or as some say substitution therapy (agonist pharmacotherapy, agonist replacement therapy, agonist-assisted therapy) is defined as the administration under medical supervision of a prescribed psychoactive substance, pharmacologically related to the one producing dependence, to people with substance dependence, for achieving defined treatment aims. Substitution therapy is widely used in the management of nicotine (nicotine replacement therapy) and opioid depen dence (methadone, buprenorphine and LAAM)
69
The prescription for substitution therapy and administration of agonists to persons with substance dependence, within the framework of recognized medical practice, approved by competent authorities, is in line w ith the
1961 and 1971 Conventions on narcotic drugs and psychotropic substances
70
and should be encouraged.
Pharmacotherapies criteria
71
The following criteria should be considered essential for a drug to be appropriate for pharmacotherapies
1.
It shows cross-tolerance and cross dependence with the psychoactive substance being used.
2.
It reduces craving and suppresses withdrawal symptoms.
3.
It facilitates psychosocial functioning and improved health.
4.
It has no short or long term toxic effects.
5.
Affordable and available
6.
Does not grossly impair psychomotor functioning
67 L. Leonard and others, “‘I inject less as I have easier access to pipes’: injecting, and sharing of crack-smoking materials, decline as safer crack-smoking resources are distributed”, International Journal of Drug Policy, vol. 19, No. 3 (2008), pp. 255-264
68 S. A. Strathdee and others, “HIV and risk environment for injecting drug users: the past, present, and future”, Lancent, vol. 376, No. 9737 (2010), pp. 268-84.
69 Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention: position paper / World Health Organization, United Nations Office on Drugs and Crime,
UNAIDS.
70 Ibid
71 WHO, Drug Substitution Project, Geneva, May 1995
11
There is a lack of agreement or general acceptance of any pharmacological interventions for stimulants and there are currently none approved for this. Despite this, there have been reports
72
of using sustained-release dextroamphetamine and dextroamphetamine as a pharmacotherapy for amphetamines and cocaine respectively.
The studies reported no adverse reactions and recommended further studies be conducted.
Cannabis has also shown promise as an alternative to crack cocaine use. More research needs to be conducted in this area but service providers should note that cannabis use should be considered therapeutic and for those individuals who turn to cannabis use should not be discouraged. There are no kno w negative interactions between cannabis and ART and cannabis use has been shown to inhibit viral progression of HIV in treatment naïve PWHIV
73
.
As stated there are no approved pharmacotherapies to treat cocaine or crack dependence
74
. Agonist medications that have similar pharmacological profiles to stimulants but have low abuse liability have been proposed as replacement therapies for cocaine dependence. One meta -analysis of randomized, placebo-controlled trials of stimulant medications for cocaine dependence showed a statistical trend favouring medication for sustained abstinence from illicit non-pharmaceutical
75
.
In addition to those illustrations used above, randomized control trials of potential medications for stimulant dependence conducted using a behavioural treatment platform that allowed ethical use of a placebo include:
bupropion for methamphetamine dependence
76
,
77
,
naltrexone for amphetamine dependence
78
, and
mirtazapine for methamphetamine dependence (in men who have sex with men)
79
.
Agonist approaches for ATS dependence show sufficient efficacy to warrant additional study to determine their utility in providing a pharmacological response to stimulant use. How this will impact on HIV transmission has yet to be studied and as stated elsewhere there is no evidence linking drug treatment outcomes and HIV.
Herbal coca leaf as a pharmacotherapy
Natural cocaine (alkaloid) which is extracted by chewing coca leaves, drinking coca infusions (teas) or ingesting food products containing powder/flour that is used as agonist substance
80
. During the coca leaf therapy patients received a nutritional supplement containing the infusion or powder of coca leaves, in addition to the alkaloid derived from chewed leaf. Currently its use is limited to Andean regions where coca products for oral and dermal use are legal and sold over the counter. C ocaine hydrochloride has also been used inside gelatine capsules for research purposes
81
,
82
,
83
,
84
and potentially could be of value as an agonist therapy out of
Andean regions (Llosa 2005).
Addressing HIV in people who use stimulants and exhibit co-morbid psychiatric conditions
While a common subgroup of people who use stimulants may be those with co -morbid psychiatric conditions
85
,
86
,
87
, harm reduction services or HIV services that integrate psychiatric care are not common. Co -
72 A Randomized, Placebo-Controlled Trial of Sustained-Release Dextroamphetamine for Treatment of Methamphetamine Addiction, Clin Pharmacol Ther. 2011 February; 89(2): 276–282. GP
Galloway,1 R Buscemi,1 JR Coyle,1 K Flower,1 JD Siegrist,1 LA Fiske,1 MJ Baggott,1 L Li,1 D Polcin,2 CYA Chen,1 and J Mendelson1 Published online 2010 December 22.; Pilot randomized double blind placebo-controlled study of dexamphetamine for cocaine dependence. Shearer J, Wodak A, van Beek I, Mattick RP, Lewis J. National Drug and Alcohol Research Centre, University of New South
Wales, Sydney, Australia. j.shearer@unsw.edu.au, Addiction. 2003 Aug;98(8):1137-41
73 Costantino CM, Gupta A, Yewdall AW, Dale BM, Devi LA, et al. (2012) Cannabinoid Receptor 2-Mediated Attenuation of CXCR4-Tropic HIV Infection in Primary CD4+ T Cells. PLoS ONE 7(3): e33961. doi:10.1371/journal.pone.0033961
74 L. Somaini and others, “Promising medications for cocaine dependence treatment”, Recent Patents on CNS Drug Discovery, vol. 6, No. 2 (2011), pp. 146-160
75 X. Castells and others, “Efficacy of psychostimulant drugs for cocaine dependence”, Cochrane Database of Systematic Reviews, No. 2, 2010
76 A. M. Elkashef and others, “Bupropion for the treatment of methamphetamine dependence”, Neuropsychopharmacology, vol. 33, No. 5 (2008), pp. 1162-1170
77 S. Shoptaw and others, “Randomized, placebo-controlled trial of bupropion for the treatment of methamphetamine dependence”, Drug and Alcohol Dependence, vol. 96, No. 3 (2008), pp. 222-232
78 N. Jayaram-Lindstrom and others, “Naltrexone for the treatment of amphetamine dependence: a randomized, placebo-controlled trial”, American Journal of Psychiatry, vol. 165, No. 11 (2008), pp.
1442-1448
79 G. N. Colfax and others, “Mirtazapine to reduce methamphetamine use: a randomized controlled trial”, Archives of General Psychiatry, vol. 68, No. 11 (2011), pp. 1168-1175
80 Llosa T, Llosa LM (2005) Oral Cocaine as Agonist Therapy in Cocaine Dependence, CPDD 67th meeting, June 2005
81 Walsh SL, Jufer R, Cone E, Bigelow GE (1998) Repeated dosing with oral cocaine in humans: pharmacodynamic and pharmacokinetic effects. CPDD 59th meeting, NIDA Res Mong Series 178: 218
82 Rush CR, Baker R, Wright K (1999) Acute physiological and behavioral effects of oral cocaine in humans: a dose-response analysis. Drug and Alcohol Dependence, 55: 1-12
83 Walsh SL, Haberny KA, Bigelow GE (2000) Modulation of intravenous cocaine effects by chronic oral cocaine in humans, Psychopharmacology 150: 361-373
84 Filmore MT, Rush CR, Hays L (2002) Acute effects of oral cocaine on inhibitory control of behavior in humans, Drug and Alcohol Dependence, 67: 157-167
85 Lopez-Quintero and others, “Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)”, Drug and Alcohol Dependence, vol. 115, Nos. 1-2 (2011), pp. 120-130
12
- 13 - morbid psychiatric conditions have been shown to be barriers to access and utilisation of harm reduction and
HIV services. There is a disproportionate representation of co -morbid psychiatric conditions in the homeless population in many places of the world. When setting targets for homeless populations it is important to consider the special nature and challenge of this sub group of people who use stimulants, have a co -morbid psychiatric condition and are ho meless.
Compulsory drug treatment for stimulant drug users
Compulsory treatments delivered inside or outside of detention centres are not efficacious for drug dependence. Often delivered on a non-voluntary basis, compulsory drug treatments constitute a violation of human rights
88
. When considering drug dependence treatment as one of numerous vectors to facilitate access to HIV prevention, treatment and care for people who use stimulants, only approaches that have evidence of efficacy, that are entered into voluntarily, and that respect public health and human rights should be tolerated and approved.
Services that do not meet that standard are not acceptable and should not be licensed
.
5. Condom programmes for people who use stimulants and for their sexua l partners
When used consistently and correctly, condoms are effective in preventing the sexual transmission of HIV and other STIs
89
,
90
,
91
. Condom programmes are effective not only in increasing condom availability but also in increasing condom use among a wide range of populations, including young people, adults, males and individuals who engage in sex work, as well as populations in areas with a high prevalence of STIs
92
. In resource-constrained countries, condom programmes continue to represent an effective , low-cost, and key intervention for preventing HIV transmission. For individuals who have used stimulants and have reported an increased libido the availability of condoms is critical in addressing sexual transmission of HIV. This is especially critical for individuals who engage in sex work, who are very sexual active with multiple partners, men who have sex with men, young people, women, and the sexual partners of stimulant users.
As much of the preponderance of HIV incidence in people who use stimula nts are sexual, information on
“condom failure” is important to capture. Recent unpublished data from an internet based survey of Caribbean men who have sex with men revealed that 27% of the respondents reported a condom failure in the last year
93
.
More information on condoms and HIV prevention is available from UNAIDS, UNFPA
94
,
95
and WHO
96
.
6. Screening, prevention and treatment of STIs, HVB, HVC, and Tuberculosis
Screening for infectious diseases such as sexually transmitted infections, hepatitis B and C , and TB at the point of contact is feasible and acceptable. Along with HIV, these are common infections often associated with illicit substance use under criminalised conditions and may co -occur with stimulant use. Data shows that people who use drugs accept, when offered, testing and treatment for hepatitis C
97
. Co-infections involving HIV, hepatitis C
86 M. J. Smith and others, “Prevalence of psychotic symptoms in substance users: a comparison across substances”, Comprehensive Psychiatry, vol. 50, No. 3 (2009), pp. 245-250
87 L. Degenhardt and W. Hall, “Extent of illicit drug use and dependence, and their contribution to the global burden of disease”, Lancet, vol. 379, No. 9810 (2012), pp. 55-70
88 United Nations Office on Drugs and Crime, “From coercion to cohesion: treating drug dependence through health care, not punishment”, discussion paper (2010). Available from www.unodc.org/docs/treatment/Coercion/Final_eBook_Sept_2010.pdf
89 United States, Department of Health and Human Services, Centers for Disease Control and Prevention, “Male latex condoms and sexually transmitted diseases”, Fact Sheet for Public Health Personnel,
2002. Available from www.cdc.gov/condomeffectiveness/latex.htm
90 United States, Department of Health and Human Services, Centers for Disease Control and Prevention, “Condoms and their use in preventing HIV infection and other STDs” (Atlanta, 1999)
91 K. K. Holmes, R. Levine and M. Weaver, “Effectiveness of condoms in preventing sexually transmitted infections”, Bulletin of the World Health Organization, vol. 82, No. 6 (2004), pp. 454-461
92 M. R. Charania and others, “Efficacy of structural-level condom distribution interventions: a meta-analysis of U.S. and international studies, 1998-2007”, AIDS and Behavior, vol. 15, No. 7 (2011), pp.
1283-1297
93 CARIMIS 2013
94 Program for Appropriate Technology in Health and United Nations Population Fund, “Female condom: a powerful tool for protection” (Seattle, 2006). Available from www.unfpa.org/webdav/site/global/shared/documents/publications/2006/female_condom.pdf
95 World Health Organization, Joint United Nations Programme on HIV/AIDS and United Nations Population Fund, “Position statement on condoms and HIV prevention” (Geneva, July 2004). Available from www.unfpa.org/upload/lib_pub_file/343_filename_Condom_statement.pdf
96 World Health Organization, Joint United Nations Programme on HIV/AIDS and United Nations Population Fund, “Position statement: condoms and HIV prevention” (Geneva, 2009). Available from www.who.int/hiv/pub/condoms/20090318_position_condoms.pdf
97 C. E. Lindenburg and others, “Hepatitis C testing and treatment among active drug users in Amsterdam: results from the DUTCH-C project”, European Journal of Gastroenterology and Hepatology, vol. 23, No. 1 (2011), pp. 23-31
13
and TB can change the treatment approaches for each condition. The benefits of providing rapid scale -up of
ART in the context of conditions correlated with drug use and HIV confers special protection against morbidity and mortality, especially for TB
98
. Additional guidelines from WHO are available
99
,
100
,
101
,
102
,
103
.
7. Behavioural interventions aimed at reducing the risk of HIV transmission
No study has shown reductions of HIV transmissions or reductions in sexual risk behaviours that correspond with reductions in stimulant use. A meta-analysis of 13 studies
104
showed no difference in effectiveness between the use of behavioural drug treatments and other types of treat ment for reducing HIV risk behaviours.
Therefore, while behavioural treatments may or may not be effective in reducing stimulant consumption, they should not be relied upon to reduce HIV transmission.
Efficacious HIV prevention interventions for people wh o use stimulants combine education about substance use, sexual risk, STIs and other concerns specific to the target population and are delivered during multiple sessions on an individual or group basis. When considering the use of behavioural interventions , their limitations, including difficulties in scalability and coverage, the need for training of staff members, the involvement of paraprofessionals or professionals and adaptations needed for culture, gender, age and context specific factors, must be carefully considered. To reach populations of people who use stimulants in stigmatising environments that make them difficult to reach by mainstream services requires outreach procedures that are non-judgmental and culturally competent.
The meaningful involvement of people who use drugs in peer-to-peer efforts is critical for the service to be effective. These services are essential to creating an environment that facilitates people to avail themselves of available resources. The Internet, text messaging and other technology-based interventions have shown promising results in promoting sexual health
105
,
106
, increasing medication adherence
107
,
108
,
109
, and reducing HIV risk behaviours
110
,
111
among various populations, including men who have sex with men, heterosexual adolescents and adults, people who inject drugs, and young people. Technology -based interventions also offer the benefit of delivering HIV prevention messages in real time, confidentially, conveniently and at a relatively low cost. To date, no controlled data on the efficacy of technology-based interventions for reducing HIV risk behaviours in people who use drugs.
Behavioural interventions with efficacy
Individual interventions allow a highly tailored and customized programme for individuals and have the best evidence guiding their use. However, in the context in which they were developed, they involve high personnel costs, are time-intensive and may not be feasible on a wide scale. In peer owned and operated environments at the grass roots level where dedicated people are engaged and available and time is more fluid, the methodology may be appropriately adapted for use with much less inputs then originally envisaged. Some examples of individual interventions that have demonstrated significant benefits in randomi zed controlled trials include:
98 K. Middelkoop and others, “Antiretroviral therapy and TB notification rates in a high HIV prevalence South African community”, Journal of Acquired Immune Deficiency Syndromes, vol. 56, No. 3
(2011), pp. 263-289
99 World Health Organization and Joint United Nations Programme on HIV/AIDS, Consultation on STD Interventions for Preventing HIV: What is the Evidence? (Geneva, 2000). Available from www.who.int/hiv/pub/sti/en/who_hsi_2000_02.pdf
100 World Health Organization, Guidelines for the Management of Sexually Transmitted Infections (Geneva, 2004). Available from www.who.int/hiv/pub/sti/pub6/en/
101 World Health Organization, Treatment of tuberculosis guidelines, fourth edition (Geneva, 2010). Available from http://whqlibdoc.who.int/publications/2010/9789241547833_eng.pdf
102 “Management of hepatitis C and HIV coinfection”, in HIV/AIDS Treatment and Care: Clinical Protocols for the WHO European Region, I. Eramova, S. Matic and M. Munz, eds. (Copenhagen,
World Health Organization Regional Office for Europe, 2007). Available from http://www.euro.who.int/__data/assets/pdf_file/0008/78146/E90840_Chapter_6.pdf
103 “Management of hepatitis B and HIV coinfection”, in HIV/AIDS Treatment and Care: Clinical Protocols for the WHO European Region, (Copenhagen, World Health Organization Regional Office for Europe, 2011). Available from http://www.euro.who.int/__data/assets/pdf_file/0011/152012/e95792.pdf
104 G. Colfax and others, “Amphetamine-group substances and HIV”, Lancet, vol. 376, No. 9739 (2010), pp. 458-474
105 M. S. Lim and others, “Impact of text and email messaging on the sexual health of young people: a randomised controlled trial”, Journal of Epidemiology and Community Health, vol. 66, No. 1
(2012), pp. 69-74
106 J. Gold and others, “A randomised controlled trial using mobile advertising to promote safer sex and sun safety to young people”, Health Education Research, vol. 26, No. 5 (2011), pp. 782-794
107 R. T. Lester and others, “Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial”, Lancet, vol. 376, No. 9755 (2010), pp.
1838-1845
108 J. Wise and D. Operario, “Use of electronic reminder devices to improve adherence to antiretroviral therapy: a systematic review”, AIDS Patient Care and STDs, vol. 22, No. 6 (2008), pp. 495-504
109 C. Pop-Eleches and others, “Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders”, AIDS, vol. 25, No. 6 (2011), pp. 825-834
110 J. Gold 2011
111 S. M. Noar, H. G. Black and L. B. Pierce, “Efficacy of computer technology-based HIV prevention interventions: a meta-analysis”, AIDS, vol. 23, No. 1 (2009), pp. 107-115
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• RESPECT — two to four counselling sessions that aim to reduce high-risk sexual behaviours, to build self-efficacy and to prevent new STIs among heterosexual adults
112
,
113
.
• EDGE — five 90-minute weekly sessions, followed by three booster sessions at three-week intervals, that focus on social cognitive strategies paired with motivational interviewing, including skills on disclosure of serostatus and safe sex negotiation
114
.
• Fast Lane — four 90-minute weekly sessions that focus on social cognitive strategies and motivational interviewing that teach skills on safer sex practices, condom use and sexual assertiveness
115
.
•
Safety Counts — seven sessions that include group and individual activities and focus on reducing high-risk sexual and drug behaviours among drug users
116
,
117
Interventions that target groups or networks may efficiently deliver information and skills training; many are tailored to specific at -risk groups to increase their acceptability. Some examples of efficacious group or network level interventions include:
• Risk Avoidance Partnership Project — the Project trains people who inject drugs and people who smoke crack cocaine to deliver an intervention on the prevention of HIV, hepatitis, and STIs to other individuals considered hard-to-reach
118
.
• Cape Town Women’s Coop — two one-hour sessions that focus on substance use, reducing the risk of
HIV and STI transmission, violence prevention and negotiation with sexual partners
119
• Peer network interventions in Chiang Mai, Thailand — youth networks received seven two-hour group sessions. One intervention was a peer educator, network -oriented intervention and the other was a life skills curriculum on methamphetamine and STIs
120
.
• Female-focused intervention for African-American women who smoke crack cocaine, two interventions
121
,
122
utilized motivation and empowerment models and addressed issues of violence and poverty.
8. Targeted information, education and communication programmes
Targeted information, education and co mmunication programmes delivered at the community level can act as a structural prevention intervention to increase awareness of links between stimulant use and HIV. Information, education and communication programmes can promote positive behaviour change such as HIV testing, condom use and other safer sex practices and can provide useful information about HIV and harm reduction appropriate to people who use stimulants. Social marketing or public health campaigns can reach large, specific populations in a cost-effective manner. During the development of messages for use in information, education and communication programmes, the meaningful involvement of people who use stimulants and are members of the community in which the message will be circulated will h elp ensure that the messages are culturally relevant and acceptable to individuals of those communities.
112 S. Semaan and others, “Brief counseling for reducing sexual risk and bacterial STIs among drug users: results from project RESPECT”, Drug and Alcohol Dependence, vol. 106, No. 1 (2010), pp. 7-
15
113 M. L. Kamb and others, “Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial — Project RESPECT Study
Group”, Journal of the American Medical Association, vol. 280, No. 13 (1998), pp. 1161-1167
114 B. T. Mausbach and others, “Efficacy of a behavioral intervention for increasing safer sex behaviors in HIV-positive MSM methamphetamine users: results from the EDGE study”, Drug and Alcohol
Dependence, vol. 87, Nos. 2-3 (2007), pp. 249-257
115 B. T. Mausbach and others, “Efficacy of a behavioral intervention for increasing safer sex behaviors in HIV-negative, heterosexual methamphetamine users: results from the Fast-Lane Study”, Annals of Behavioral Medicine, vol. 34, No. 3 (2007), pp. 263-274
116 M. J. Rotheram-Borus and others, “Reducing HIV risks among active injection drug and crack users: the safety counts program”, AIDS and Behavior, vol. 14, No. 3 (2010), pp. 658-668
117 F. Rhodes and G. L. Humfleet, “Using goal-oriented counseling and peer support to reduce HIV/AIDS risk among drug users not in treatment”, Drugs and Society, vol. 7, Nos. 3-4 (1993), pp. 185-204
118 M. R. Weeks and others, “The Risk Avoidance Partnership: training active drug users as peer health advocates”, Journal of Drug Issues, vol. 36, No. 3 (2006), pp. 541-570
119 W. M. Wechsberg and others, “Alcohol, cannabis, and methamphetamine use and other risk behaviours among Black and Coloured South African women: a small randomized trial in the Western
Cape”, International Journal of Drug Policy, vol. 19, No. 2 (2008), pp. 130-139
120 S. G. Sherman and others, “Evaluation of a peer network intervention trial among young methamphetamine users in Chiang Mai, Thailand”, Social Science and Medicine, vol. 68, No. 1 (2009), pp.
69-79
121 C. E. Sterk, K. P. Theall and K. W. Elifson, “Effectiveness of a risk reduction intervention among African American women who use crack cocaine”, AIDS Education and Prevention, vol. 15, No. 1
(2003), pp. 15-32
122 W. M. Wechsberg and others, “Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African American crack abusers”, American Journal of Public Health, vol. 94, No. 7 (2004), pp. 1165-1173
15
Some groups have developed community-based websites (e.g. www.tweaker.org) that provide information about methamphetamine use, HIV risk and harm-reduction techniques. Such sites commonly provide online forums or other remote peer support for people who use stimulants where alternatives may be shared among users that support informed choices. Many of these websites have not undergone formal evaluation; however, their reach is wide: tweaker.org reports receiving over 2,300 visitors per day and has over 6,000 followers on
Facebook.
While such programmes may bring information efficiently and in a culturally competent manner to large and hidden populations, their efficacy in preventing HIV transmission (as measured using prevalence or incidence markers) is unknown. In one targeted publicity campaign on the use of crystal methamphetamine and HIV by men who have sex with men, 62 per cent of survey respondents reported that they had seen the information adverts, and men of colour said that they were more likely to have conversations about crystalline methamphetamine use as a result
123
.
Information, education and communication efforts involving social marketing or public health campaigns can shift their outcome from increasing awareness to providing persons with information related to sexual and drug use behaviours, so they have the information needed to make informed decisions if they so select to.
Factors to consider when planning, implementing and evaluating HIV interventions
“Polydrug” use
People who use stimulants exhibit certain preferences for specific psycho -stimulants. The proximity of a diverse drug market that offers a wide range of stimulant choices will facilitate an environment conducive to
“stimulant switching”
124
. Factors that affect preference include “half-lives”. Cocaine and crack have short halflives (30-45 minutes for powder cocaine; 2-10 minutes for crack); compared with ATS (9 -12 hours for amphetamine and methamphetamine; 4-5 hours for ecstasy). Due to its ease of availability, alcohol consumption is obtainable to those who wish to use it concurrently with their stimulants.
Some people who use cocaine or crack may also use alcohol. Drinkin g alcohol and using cocaine or crack concurrently or in near time produces coca-ethylene, a compound that has psychoactive properties and biological impacts that are unique from that of its constituent parts
125
.
A common poly-drug use among some people who use drugs - whether injecting, smoking or snorting - is to integrate the use of opioids and stimulants, a practice known as “speedballing”. Each type of polydrug use may present unique challenges to developing specific interventions that address the myri ad of factors that result from substance mixing.
People who inject stimulants
Given the “half life” issues as discussed above, some people who inject stimulant such as cocaine or ATS may inject more often than a person who is injecting opioids and requir e more sterile syringes than the service user who injects opioids exclusively. In order to serve the needs of this sub group of people who inject drugs it is important for sterile syringe programmes to adapt the information and education they provide to em phasize the need for safe injecting and safe sexual practices.
123 J. E. Nanín and others, “Community reactions to campaigns addressing crystal methamphetamine use among gay and bisexual men in New York City”, Journal of Drug Education, vol. 36, No. 4
(2006), pp. 297-315
124 World Drug Report 2012
125 E. D. Herbst and others, “Cocaethylene formation following ethanol and cocaine administration by different routes”, Experimental and Clinical Psychopharmacology, vol. 19, No. 2 (2011), pp. 95-104
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Sexual risk behaviours concomitant to stimulant use
Stimulant use has been shown to increase frequency of sexual intercourse and thereby increasing the vulnerability to HIV
126
,
127
. When stimulant-associated unprotected sex occurs in the context of concurrent sexual partnerships (in which individuals report at least two partners for which first sex was reported as having occurred at least six months earlier, and the most recent sex is reported as having occurred no more than six months earlier), the probability of HIV transmission is increased
128
. In countries where the HIV epidemic is localized in populations of men who have sex with men, stimulant use accounts for an attributable fraction of incident infections, ranging from 16 to 36 per cent
129
,
130
. In the context of both generalized and concentrated epidemics, stimulant use reduces inhibitions sufficiently to facilitate sex work, to promote sexual exploration and/or to overcome feelings of stigma and internalized homonegativity.
Women
Women who use stimulants face additional and unique challenges. One of the main challenges is the cross cultural stigma associated with their vacating gender roles such as caring for their family and being pregnan t or mothers of infants and children
131
. Women face power dynamics in relationships and higher rates of poverty; those factors interfere with their ability to access reproductive health supplies, including condoms and other contraceptives
132
. Such situations are particularly common among women who use drugs
133
. Women who use stimulants have elevated risks for HIV transmission, STI, and high rates of partner violence
134
,
135
.
Young people
In generalized epidemics, 40 per cent of all new HIV infections occur among yo ung people aged 15-24, with girls and young women disproportionately affected, making them a priority for HIV prevention
136
. The risk for
HIV acquisition among young people varies by region, with risk rates higher in countries with higher HIV prevalence.
Young people, especially those below the age of majority have a difficult time accessing service without parental consent. This age is 4 to 6 years past the age of sexual initiation or experimentation with psychoactive substances creating a “service denied” age range. The early onset of sex initiation and the age barriers further exacerbates an already wide disparity between need and accessibility. Stimulant -using young people who are homeless are exceptionally vulnerable and present additional challenges t o the process of reducing HIV and other BBV among this population.
Co-morbid psychiatric conditions
Some people have both psychiatric issues and use stimulants. These people with co -morbid condition are multiply vulnerable to a number of external fact ors.
126 A. Rajasingham and others, “A systematic review of behavioral and treatment outcome studies among HIV-infected men who have sex with men who abuse crystal methamphetamine”, AIDS Patient
Care STDS, vol. 26, No. 1 (2012), pp. 36-52
127 C. D. Parry and others, “Methamphetamine use and sexual risk behaviours in Cape Town, South Africa: a review of data from 8 studies conducted between 2004 and 2007”, African Journal of
Psychiatry, vol.14, No. 5 (2011), pp. 372-376
128 P. M. Gorbach and K. K. Holmes, “Transmission of STIs/HIV at the partnership level: beyond individual-level analyses”, Journal of Urban Health, vol. 80, Suppl. 3 (2003), pp. iii 15-iii 25
129 B. A. Koblin 2006
130 D. G. Ostrow (2009)
131 M. L. Brecht and others, “Methamphetamine use behaviors and gender differences”, Addictive Behaviors, vol. 29, No. 1 (2004), pp. 89-106
132 World Health Organization, Joint United Nations Programme on HIV/AIDS and United Nations Population Fund, “Position statement: condoms and HIV prevention” (Geneva, 2009). Available from www.who.int/hiv/pub/condoms/20090318_position_condoms.pdf
133 W. A. Zule and others, “Methamphetamine use and risky sexual behaviors during heterosexual encounters”, Sexually Transmitted Diseases, vol. 34, No. 9 (2007), pp. 689-694
134 M. C. Couture and others, “Correlates of amphetamine-type stimulant use and associations with HIV-related risks among young women engaged in sex work in Phnom Penh, Cambodia”, Drug
Alcohol Dependence, vol. 120, No. 1-3, pp. 119-26
135 J. B. Cohen and others, “Methamphetamine Treatment Project, Abuse and violence history of men and women in treatment for methamphetamine dependence”, American Journal on Addictions, vol. 12, No. 5, pp. 377-85
136 Joint United Nations Programme on HIV/AIDS, “Global Report 2012 Epidemiology slides” (2012)
17
The mechanism and relationship between psychiatric conditions and substance use is unclear. In some, the psychiatric issue has clearly manifested prior to the initiation of stimulant use. For others, this relationship is not as clear and raises the question of whether there was undetected but pre-existing disposition to psychiatric illness. Further, it is not clear how the context of an “undetected but predisposed” co -morbid condition contributes to some psychiatric conditions that manifest concurren tly with the chronic use of stimulants. (e.g. drug-induced psychosis or mania)
137
,
138
. People who use stimulants with co-morbid psychiatric conditions may experience exaggerated impacts of poverty, stigma and gender-related violence (for females) that increase their vulnerability to HIV by the likelihood of engaging in behaviours that place them at elevated risk of transmission. Stimulant-using women who are also living with HIV face significantly enhanced risks for psychiatric and HIV-related morbidities
139
,
140
.
IV. Target-setting process
The following section is adapted from a framework that was developed and used with respect to injecting drug users
141
. For each of the nine interventions in the comprehensive package, a series of indicators are described to assess:
Availability
Coverage
Quality
Potential impact
It is recommended that at least five of the nine interventions:
HIV testing and counselling,
ART for HIV-infected stimulant users,
harm reduction services and other evidenced based drug dependence tr eatment,
condom programmes for people who use stimulants and for their sexual partners,
and needle and syringe programmes for people who inject stimulants, are included and monitored as a minimum for a comprehensive strategy. Where possible, gender -disaggregated
(male, female, transgendered) data should be collected and reported for those indicators. Ongoing monitoring and evaluation of each of these interventions as they are implemented is crucial. It is recognised, however, that organisations are at different stages of readiness to establish a comprehensive response that addresses the challenges presented by people who use stimulants.
A. Pre-planning for the target-setting process
Pre-planning can assist in allocating resources and may include:
Identifying resources or a budget that can be allocated to target -setting for people who use stimulants
Collecting markers of HIV incidence and prevalence among people who use stimulants
Documenting the types of transmission behaviours experienced by people w ho use stimulants
137 L. Degenhardt and W. Hall (2012)
138 C. Lopez-Quintero and others (2011)
139 J. A. Cook and others (2008)
140 J. A. Cook and others, “Illicit drug use, depression and their association with highly active antiretroviral therapy in HIV-positive women”, Drug and Alcohol Dependence, vol. 89, No. 1 (2007), pp. 74-
81
141 WHO, UNODC, UNAIDS Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users (Geneva, World Health Organization,
2009), Available from www.who.int/hiv/pub/idu/idu_target_setting_guide.pdf
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Creating an inventory of the types of services available for people who use stimulants (e.g. ART, harm reduction services, condom programmes, sterile syringe programmes, and information, education and cultural programmes)
Gathering costs for units of service for available programmes
Considering the need for sensitivity training and increasing the awareness of people who use stimulants and their needs during the target-setting process
B. Environment
It is necessary to understand the environment and target populations in order to successfully implement and monitor interventions. Individuals who use stimulants display wide variability in the frequency and amount of their stimulant use and the experiences and consequences of that use. The vu lnerability of people who use stimulants to HIV transmission may also vary, depending largely on the HIV serostatus and HIV viral load of their partners, the “HIV incidence” of community in which they are and on whether their partners have any other STIs.
This complicates the task of promoting a uniform approach to setting targets. For example, some may use stimulants to accomplish “functional” tasks that require sustained attention (truck driving) or to engage in sex work, while others may use stimulants recreationally to get high or brighten their mood, to facilitate sexual adventurism or to counter feelings of stigma, discrimination or internalized homo -negativity. As such, countries may find it helpful to construct the target -setting activities around venues where people who use stimulants can be contacted (e.g. clubs, saunas and other entertainment places that cater to men who have sex with men, drop in centres for street engaged people who use stimulants, settings that specialise in caring for women, prisons, and medical settings). It may also be useful to include target -setting activities in locations where people who use stimulants may access other care services (e.g. community -based organizations, faithbased organizations and shelters) as a way of expanding intervention coverage.
C. Estimating populations of stimulant users at risk
In order to set targets and monitor outcomes, many of the indicators described in this Technical Guide are measured by the number of people who use stimulants that require assistance . Examples include national estimates of the number of individuals who use cocaine, crack and ATS, both via injecting and non -injecting routes.
Estimating the size of the population of individuals who use cocaine, crack, methamphetamine, amphetamines and ecstasy and who face HIV transmission risks
Three definitions are commonly used to define different levels of stimulant users: lifetime use (any use at all), use in the previous 12 months (recent use) and use in the previous 30 days (curre nt use). Surveys of people who use drugs typically include questions about stimulant use within those three time frames. For the purpose of reporting on the indicators described in this Technical Guide , it is recommended that the marker of recent use (those who report having used those drugs at any time during the previous 12 months) be used to define a wide population of individuals who use cocaine, crack or ATS. In addition, the marker of current use (those who report they have used these drugs at any time during the previous month) can identify a smaller, refined population of individuals who regularly use stimulants. Both measures of stimulant use are important and should be collected if possible.
Estimating the size of the target population for different interventions
People who use stimulants are a diverse group (users of cocaine, crack and ATS, as well as polydrug users) with different characteristics (gender, sexual behaviours, HIV serostatus, co -morbid conditions, psychiatric disorders etc.). Important subgroups to consider and assess in methods that allow disaggregation:
19
• Gender: women, men, transgender
• Sexual behaviours: men who have sex with men, bisexual, heterosexual. This information, while sensitive, is essential to informing target-setting in concentrated epidemics involving men who have sex with men and bisexual men.
• Polydrug users: it is important to include in the estimation some indication of the group of individuals who are polydrug users, specifically people who use stimulan ts who also use opioids (heroin and prescription medications) and/or alcohol.
• People who inject drugs: in many countries, people self-inject prescribed pharmaceuticals for medical purposes (e.g. insulin for the management of diabetes). This practice is known as therapeutic injection, is sanctioned by the state and occurs under sterile conditions. Persons who self -inject for medical purposes only are not included in the definition of people who inject drugs for the purpose of this Guide.
This Guide focuses on mitigating the harms caused by the injection of illicit substances manufactured under conditions of stealth rather than hygiene, diluted with unnamed and often harmful “fillers”, procured in an illicit marketplace often known for violence, and used surreptitiously, which creates a context that promotes vulnerability to HIV infection. Included in this sub -group are people who procure legally manufactured pharmaceuticals on the illicit market and use them in the same criminalised context.
• People who use stimulants who also have co-morbid psychiatric conditions and are homeless are highly likely to suffer from bipolar disorders
142
and psychotic disorders
143
and be at high risk for exploitation and abuse including sexual abuse and rape. This is particularly true of women meeting these criteria.
Measurement of target indicators
Members of targeted subgroups are frequently culturally or otherwise isolated from public health efforts and referred to as “hidden”. They require special attention to facilitate their access and utilisation of services.
Strategies such as behavioural surveillance methods not only identi fy individuals within those subgroups, but can also yield data about how HIV transmission risks occur within subgroups
144
.
Recall periods
To respond to technologies for measuring sexual risk behaviours, recall periods for sexual behaviours can include the previous 3 months (90 days) in addition to the current (1 month) and recent (previous 12 month s) recall periods, the same as used for measuring drug use.
Drug use and sexual risk episodes
Survey data generally assess reported stimulant use and high -risk sexual transmission behaviours separately, which separates temporal relationships. This challenge may be addressed by assessing stimulant users’ reported unprotected vaginal and/or anal sexual behaviours during or immediately before (within two hours of) their use of stimulants.
Risk behaviours in the presence of HIV
It is important to identify the subgroups who report engaging in unprotected sex during or immediately before their use of stimulants with a partner whose HIV serostatus is unknown or unconfirmed. Measuring the combined impact of stimulant use and sexual risk behaviour involving a partner whose HIV serostatus is unknown or unconfirmed reduces the risk of overestimating the subgroup size.
142 Family Health International, Behavioral Surveillance Surveys (BSS): Guidelines for Repeated Behavioural Surveys in Populations at Risk for HIV (Arlington, Virginia, 2000). Available from www.ternyata.org/wp-content/uploads/2010/02/BSS_Eng.pdf
143 M. J. Smith and others (2009)
144 Family Health International, Behavioral Surveillance Surveys (BSS): Guidelines for Repeated Behavioural Surveys in Populations at Risk for HIV (Arlington, Virginia, 2000). Available from www.ternyata.org/wp-content/uploads/2010/02/BSS_Eng.pdf
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Guidance on size estimation methods
The use of cocaine, crack and ATS is illegal and as such survey respondents are thereby admitting to illegal behaviour if they give details of their use of such d rugs. It may be useful to use indirect estimation methods, such as multiplier and benchmark calculations, which make use of existing data sources (such as police arrests or drug dependence treatment) or capture-recapture methods. Guidance on these methods is available in several publications
145
,
146
[135-138].
D. Availability of interventions
Indicators of availability measure whether an intervention is available to the population of stimulant users. For most of the interventions, availability is measured as a simple “present” or “absent” observation. In some countries, ART may not be available to stimulant users and this should be noted. For most of the interventions in this Technical Guide , the extent of availability is defined as the number of sites offering the specific intervention per 1,000 users of cocaine, crack or ATS. While this proportion is a crude marker of availability across the population, more detailed information assembled during data collection (e.g. identifying areas where users are concentrated and identifying agencies and areas where interventions are located) can be useful for guiding policy to increase access to available interventions. Representation of this data graphically using either paper maps or computer based geographical information systems will assist in presenting data in a observer friendly way to policy makers, when seeking to secure resources to provide services.
In addition, in countries, regions or on the local level where distinct sub-groups indentified their stimulant of choice, calculation of separate indicators of availability for each population for each intervention may be useful to help develop population appropriate programmes .
E. Coverage of interventions
In this Technical Guide , the term “coverage” is used to describe the extent to which an intervention is delivered to the target population (i.e. the proportion of the target population in need of an intervention that actually receives it). The definition of “coverage” as the number of individuals reached by an int ervention could refer to any contact, not just an “effective” contact. How often a person accesses a service is also important. PWHIV stimulant users who access HIV care every 3 -6 months are qualitatively better off than those who receive HIV care on a less frequent basis. Among the general population of stimulant users, those who access HIV testing and counselling every 12 months have qualitatively less accurate information about their HIV status than those who access HIV testing and counselling every 3 -6 months. Condom programmes have demonstrable benefit when accessed weekly and, for drug dependence treatment, opioid pharmacotherapy is most effective when accessed daily.
This situation highlights the importance of distinguishing between the number of cl ients (individuals) accessing a service and the number of client contacts for the service. For individuals who access HIV testing and counselling, it may be difficult to identify return or duplicate contacts. Using a unique identifier code for each individual is one way to address this problem while maintaining the privacy and confidentiality of patient information (e.g. in the Caribbean the universal code used throughout the region comprises the initials of the individuals first and last name, the initials of the individuals mother’s name, gender (M/F) and 6 digits representing their day/month/year of birth). For individuals who access condom programmes in which open and free access is provided, it is not practical to use a unique identifier code, so a more helpful approach would be to record the number of condoms distributed weekly or monthly and the number of stimulant users who access the programme, and use those markers to develop an estimate of coverage.
145 Joint United Nations Programme on HIV/AIDS and World Health Organization, Guidelines on Estimating the Size of Populations Most at Risk to HIV: UNAIDS/WHO Working Group on Global
HIV/AIDS and STI Surveillance (Geneva, 2010). Available from www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2011/2011_Estimating_Populations_en.pdf
146
21
F. Quality of interventions
“Quality” encompasses the scope, completeness, effectiveness, efficacy and safety of interventions. The quality of an intervention makes a vital difference to its impact on the HIV epidemic. For example, people who use stimulants that initiate ART after an AIDS-defining event will have poorer outcomes than those that initiate it earlier (e.g. when the individual’s CD4 counts are greater than or equal to 500 copies per millilitre). HIV testing and counselling and condom programmes that limit the number of times that people who use stimulants may access the services in a year will have lower effectiveness in supporting individuals to limit their risks for
HIV transmission.
The quality of provider-initiated HIV testing and counselling can be gauged by using WH O, UNODC,
UNAIDS guidelines. Quality includes the extent to which all patients, irrespective of substance use, are provided access to:
testing and counselling as a standard part of clinical ca re for STIs and for family planning,
in pre-natal and antenatal settings and medical care for all patients (children and adults)
and in selective settings in concentrated epidemics (e.g. specialised health-care clinics for men who have sex with men, sex workers, people who use drugs).
Additional markers of quality for HIV testing a nd counselling are whether the users can “opt out” of the services and whether the services are voluntary and conducted only with consent.
Quality indicators to measure the provision of ART are available and one indicator of service quality maybe gauged by whether or not providers use these guidelines when delivering ART to PWHIV. Quality indicators are more useful if disaggregated by gender (e.g. M/F/T) and by sexual behaviour (e.g. engages in receptive anal intercourse) in order to evaluate whether the quality of care varies for these subgroups.
Another indicator of quality is whether HIV-infected individuals can disclose their use of stimulants or other substances to their provider without compromising their safety or their access to ART.
For individuals who seek post-exposure prophylaxis, pre-exposure prophylaxis or other combination prevention approaches that integrate the use of ART, quality can be measured by whether access is available, in this case, to people who use stimulants.
As stated above the effectiveness of abstinence based drug dependence treatment programmes to people who use stimulants in preventing HIV is no better than other interventions tested to prevent HIV transmission.
A marker of quality for opioid pharmacotherapy programmes attended by people who use stimulants would be whether they include information, education and communication programmes or behavioural interventions that address stimulant use and sexual concurrency
147
.
Another important marker of quality is whether services are on offer for people with co-morbid psychiatric disorders directly and/or uses referral processes to agencies that provide psychiatric care.
Quality indicators for condom programmes should be used for all sites where condoms are available , easily accessible and free, including sterile syringe programmes. Male condoms are the most effective prevention tool for sexual transmission of HIV, so they should be widely available and free. Female condoms are more effective for protection against ulcer like STIs, though not as widely available as male condoms.
Quality indicators of sterile syringe programmes include whether they deliver services that reflect best practices. Proximal indicators of quality of sterile syringe programmes include:
convenience of access to services (in terms of hours and location),
services that cater for and are attractive to people who inject stimulants including women, the homeless population, men who have sex with men, sex workers and polydrug users
meaningful involvement of people who inject drugs in the running of the programme and
a good working relationships with neighbours and police to ensure safety and access
148
.
147 J. Marsden and others, “Development of the treatment outcomes profile”, Addiction, vol. 103, No. 9 (2008), pp. 1450-60
148 Australia, Victorian Department of Human Services, “National Needle and Syringe Programs: Strategic Framework 2010-2014” (2010). Available from www.health.gov.au/internet/main/publishing.nsf/Content/0CF549E9268148FCCA2578000008F55B/$File/frame.pdf
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One indicator of quality for evidence-based HIV prevention interventions involves assessing the programme delivery against published manuals and materials that detail implementation protocols and populations targeted. Expected outcomes can vary when adapting interventions for groups that are different from those for which the programme was initially developed.
As “motivation to engage” in behavioural treatments has been shown to be an important component of the effectiveness of such treatments, a quality marker is whether or not the programmes are delivered on a voluntary basis.
One indicator of quality for screening of conditions such as STIs, TB, hepatitis B and hepatitis C that are commonly co-morbid with HIV among people who use stimulants is whether service sites offer on-site screening for those conditions.
A marker of quality for public health programmes that screen for infectious diseases such as HIV, STIs, TB, hepatitis B, hepatitis C is whether or not use of cocaine, crack or ATS is assessed during screening.
Assessing the quality of information, education and communication programmes is difficu lt because they often target widespread groups and have no cost effective, reliable measure of their impact on such groups. It may be possible to estimate how many people have seen a marketing campaign or to ask how a campaign has affected their behaviour, but this becomes less feasible as the scale increases.
The best quality indicators of targeted information, education and communication programmes may be their accessibility by a particular group and the meaningful involvement of that group in the development and piloting of the programmes.
Additionally, given the stigma related to drug use, one important marker of quality across all types of services is whether measures of client satisfaction or “user-friendliness” are collected as part of service delivery.
Ultimately, an intervention is only effective if it is accessible and utilised.
Available services that have barriers that inhibit utilisation are little better than no service at all.
G. Potential impact of interventions
The overall purpose of using this Technical Guide is to provide direction for service providers and policymakers to implement interventions and measure impact of universal access to HIV prevention, treatment and care for people who use stimulants. The most rigorous indicators of such impact are biomarkers (e.g. viral load and CD4 counts) that are measured across proportions of people who use stimulants, showing HIV disease that is well controlled. Evidence has shown that ART adherence overrides the negative effects that stimulants have on the immune system
149
,
150
. For people who use stimulants and are not HIV+ a reduction or elimination of HIV incidence is the most stringent impact marker.
When setting targets, it is important to consider that access to ART by PWHIV who use stimulants may vary by country or by region. It is also important to consider if a country or region has the means for regularly and centrally recording viral load and/or CD4. Moreover, the availability of HIV biomarkers that contain integrated data detailing use or non-use of stimulants may be even more variable. The high levels of stigma faced by
PWHIV who use stimulants, particularly women of childbearing age or who provide for their family members, and the stigma associated with stimulant and other substance use, make it more difficult to develop impact measures of disease status in the population.
Measuring HIV incidence is the best way of measuring the impact of HIV prevention interventions. However, studies on HIV incidence are rare, as they require the mon itoring of large cohorts, which is a resource intense and potentially difficult task at best and further complicated when highly criminalised, stigmatised populations ,
149 R. J. Ellis and others (2003)
150 S. Shoptaw and others (2012)
23
such as people who use stimulants, are being monitored. Some methods for estimating HIV incidence using cross-sectional measures (e.g. detuned assays) can provide information that may be sufficient for estimating
HIV prevalence and incidence in repeated surveys.
HIV prevalence is a less rigorous method of assessing the potential impacts of setting and monitoring targets to ensure access to HIV prevention, treatment and care for people who use stimulants. Prevalence estimates are extremely vulnerable to sampling biases, especially when sampling subgroups of people who use stimulants
(e.g. women, men who have sex with men and polydrug users). Even if decreases are observed in prevalence, these potential biases interfere with the ability to state with confidence that the lowered levels reflect a slowing of the epidemic. Application of mathematical modelling solutions may help to increase some confidence in the data, but it remains the case that incidence markers are far superior.
H. Data sources
Data required for the indicators discussed above can be gathered from multiple sources. In most coun tries and regions, these data are not collected by a single agency or centrally organized or collated. Having a single, national agency that is supported in the collation and reporting of national data on a regular basis is advantageous. Data collected by services (programme data) can be used to determine the number and type of services provided and the number and characteristics of individuals who access those services. The coverage of interventions can be monitored by programme data, with the exception of condom programmes, which may be best monitored by the number of sites that conduct programmes that target individuals who use cocaine, crack and ATS.
Another key source of data are behavioural and seroprevalence surveillance surveys. Guides exist to aid implementation of such surveys
151
. Such surveys offer an efficient method for collecting specific information about the characteristics of individuals who use cocaine, crack and ATS, their HIV and other infectious disease status, and their current and historical sexual and drug-related behaviours that may place them vulnerable to
HIV transmission. This type of activity can be helpful when implemented as part of sentinel surveillance of people who use stimulants and when conducted at HIV testing and counselling sites. Although it may be challenging to collect this sensitive information, it is very useful to measuring the impact and success of implemented strategies.
Infectious disease registration systems may be able to provide data on registered cases of HIV, AIDS and viral hepatitis.
I. Setting targets
There is no universal approach to the target-setting process. While there is limited evidence to assist in defining minimum levels of coverage or thresholds required for these interventions to achieve a desired impact, there is strong evidence that access to and utilisation of these interventions are protective factors against HIV transmission. Similarly access to and utilisation of these interventions also improves health outcomes for
PWHIV and people who use stimulants should not be excluded from them.
As noted earlier, people who use stimulants are not a monolithic group. Women, sex workers, men who have sex with men, homeless persons, polydrug users, individuals with psychiatric co -morbidities and individuals in prison or criminal justice settings are some of the broader subgroups of people who use stimulants and who are at increased vulnerability to HIV. It is not uncommon for individuals to be part of multiple networks, groupings or identities that comprise these subgroups. Each subgroup has different affinities for congregating and varying levels of success when interacting with different components of the public health system. Subgroups may experience very different outcomes that are as much influenced by context in which the subgroup exists as they are by personal determination.
151 Family Health International, Behavioral Surveillance Surveys (BSS): Guidelines for Repeated Behavioural Surveys in Populations at Risk for HIV (Arlington, Virginia, 2000). Available from www.ternyata.org/wp-content/uploads/2010/02/BSS_Eng.pdf
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Thus, a “one-size-fits-all” approach may have limited utility. Collecting evidence from subgroups of stimulant users may require substantial efforts. Yet the knowledge gaine d promises to yield higher-quality information that can guide allocations of costs and resources for stimulant users.
Reflecting on these challenges and gaps, the indicative target levels presented in this Technical Guide are based on current expert consensus and coverage levels achieved in countries that have had the greatest impact on reducing or avoiding high levels of HIV infection among individuals who use cocaine, crack and ATS.
Different indicative targets, expressed as a range, are provided for eac h intervention.
Taking into account the indicative target levels proposed in this Technical Guide , Stakeholders and policymakers should set their own targets for each intervention based on the situation in their country. They should agree on a credible measure of the target population and decide on an ambitious but realistic target to measure the impact of the appropriate interventions selected from the comprehensive package. The target’s ranges allow an indication of the quantitative or qualitative impact a programme is making on the epidemic, with the lower ranges indicative of less of an impact on the epidemic than the higher ranges. Additional guidelines on target settings from UNAIDS are available
152
,
153
.
152 Joint United Nations Programme on HIV/AIDS, Scaling Up Towards Universal Access: Considerations for Countries to Set their Own National Targets for AIDS Prevention, Treatment, and Care
(Geneva, 2006). Available from http://data.unaids.org/pub/Report/2006/considerations_for_target_setting_april2006.pdf
153 Joint United Nations Programme on HIV/AIDS, Operational Guidance on Setting National Targets for Moving Towards Universal Access (Geneva, 2006). Available from http://data.unaids.org/pub/guidelines/2006/20061006_report_universal_access_targets_guidelines_en.pdf
25
Annex I. Methodology used in developing the Technical Guide
In the development of the present Technical Guide , a systematic and comprehensive search of the published literature using electronic libraries, including PubMed (www.ncbi.nlm.nih.gov/pubmed), PsycINFO
(www.apa.org/pubs/databases/psycinfo/index.aspx) and Sociological Abstracts
(www.csa.com/factsheets/socioabs-set-c.php), was conducted. Key search terms used included “HIV”, “AIDS”,
“human immunodeficiency virus”, and “acquired immunodeficiency syndrome”, in combination with stimulant drug terms such as “cocaine”, “crack cocaine”, “cocaine-related disorders”, “cocaine hydrochloride”,
“amphetamine-type stimulant”, “amphetamine”, “methamphetamine”, “methylamphetamine” and “ d amphetamine”. A review of the “grey” literature was also conducted, which in volved reviewing relevant reports and presentations from various websites of governmental and non -governmental bodies, conferences and research centres. There were limitations to the review as not all papers could be obtained and only publications available in English were included.
Articles were screened for inclusion based on the following criteria:
Focus on an HIV or AIDS intervention (e.g. behavioural, biomedical, antiretroviral therapy (ART) or education)
Inclusion of an outcome evaluation (e.g. randomized control trials)
Study sample of people who use drugs (use within the last 12 months) with crack, cocaine and/or amphetamine-type stimulants (ATS) as the primary drug of use (at least 50 per cent of the sample needed to report stimulant use), regardless of route of administration (e.g. injection or non-injection)
Assessed at least one of the following HIV-related outcomes: o Sexual behaviours (e.g. abstinence, mutual monogamy, number of sexual partners, negotiation of safer sex and condom use) o Drug use behaviours (e.g. frequency of drug use and injection use) o Biomarkers of HIV or other sexually transmitted infections (e.g. viral load, CD4 counts and incidence or prevalence measures)
The limited number of randomized clinical trials evalu ating HIV interventions for stimulant-using populations led to the inclusion of other interventions (e.g. ART, condom programmes) that show efficacy. A draft version of the document was prepared on the basis of this evidence . An electronic consultation with international experts was conducted to provide initial feedback on the document, followed by a three -day in person meeting to review the guide. A second round of revision and electronic consultation was conducted, resulting in the current version of the guide.
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Annex II. Framework for setting indicators and indicative targets
1. HIV testing and counselling
Availability
1.1. Is HIV testing and counselling available for people who use stimulants?
Yes/No
1.2. HIV testing and counselling sites per 1,000 people who use stimulants
Data source:
Numerator:
Programme data
Number of sites offering HIV testing and counselling for people who use stimulants
Denominator:
Target:
(Number of people who use stimulants)/1,000
Context-specific (should consider geographical distribution of the target population and other local factors influencing accessibility)
Coverage
1.3. Percentage of people who use stimulants who have had an HIV test in the previous 12 months and who know the results
Data source:
Numerator:
Behavioural surveillance surveys
Number of people who use stimulants in the sample tested for HIV during the previous 12 months and who know their results
Number of people who use stimulants in the sample Denominator:
Or alternatively :
Data source:
Numerator:
Programme data
Number of people who use stimulants who have been tested for HIV during the previous 12 months and who have received the results
Denominator:
Targets:
Number of people who use stimulants in the sample
Low: <40 per cent
Medium: >40-<75 per cent
High: >75 per cent
Quality
1.4. Is the HIV testing and counselling offered voluntarily and with consent?
Yes/No
1.5. Is the HIV testing and counselling provided as a standard option with an “opt -out” alternative?
Yes/No
1.6. Percentage of sites adhering to World Health Organization (WHO) guidelines on HIV testing and counselling
27
Data source:
Numerator:
Programme data
Number of sites offering HIV testing and counselling and adhering to WHO guidelines .
154
,
155
Denominator:
Targets:
Number of HIV testing and counselling sites
Low: <50 per cent
Medium: >50-<80 per cent
High: >80 per cent
Potential impact indicators
1.7. Increase in percentage of people who use stimulants aware of their HIV status
Data source:
Numerator:
Behavioural surveillance surveys
Number of people who use stimulants who are aware of their status, as confirmed by testing
Number of people who use stimulants Denominator:
1.8. Increase in percentage of people who use stimulants who test positive for HIV and who are referred and assessed for antiretroviral therapy (ART)
Data source:
Numerator:
Denominator:
Programme data
Number of people who use stimulants who test positive for HIV and who are referred and assessed for ART
Number of people who use stimulants who test positive for HIV
2. Antiretroviral therapy
Availability
2.1. Is ART available to people who use stimulants?
Coverage
Yes/No
2.2. Percentage of HIV-infected stimulant users receiving ART
Data source:
Numerator:
Programme data; HIV prevalence data
Number of people who use stimulants receiving ART
Denominator:
Targets:
Comment:
Number of PWHIV who use stimulants for whom ART is indicated
Low: <25 per cent
Medium: >25-<75 per cent
High: >75 per cent
If the number of PWHIV who use stimulants requiring ART is not available, the number of all PWHIV who use stimulants could be used instead. It is important to note the limitations to estimating the number of PWHIV who use stimulants using a measure of HIV
154 World Health Organization and Joint United Nations Programme on HIV/AIDS, Guidance on Provider-Initiated HIV Testing and Counseling in Health Facilities (Geneva, 2007). Available from www.who.int/hiv/pub/guidelines/9789241595568_en.pdf
155 World Health Organization and United Nations Office on Drugs and Crime, Guidance on Testing and Counselling for HIV in Settings Attended by People Who Inject Drugs: Improving Access to
Treatment, Care and Prevention (Geneva, 2009). Available from www.who.int/hiv/topics/idu/care/GuidanceTC_IDUsettings.pdf
28
- 29 - prevalence among people who use stimulants and an estimate of the total number of people who use stimulants, given the uncertainty of both the HIV prevalence and stimulant estimates. Given that the highest ART coverage is 75 -80 per cent in high-income countries, more than 75 per cent is defined as high-level coverage.
2.3. Ratio of people who use stimulants in receipt of ART
Data source:
Numerator:
Denominator:
Targets:
HIV registration data, ART programme data and treatment surveys
Number of PWHIV who use stimulants receiving ART/total number receiving ART
Number of PWHIV who use stimulants /total number of HIV cases
>1 is desirable
Quality
2.4. Percentage of sites adhering to WHO guidelines on ART
156
Data source:
Numerator:
Denominator:
Targets:
Programme data
Number of ART sites adhering to WHO guidelines on ART
Number of ART sites
Low: <50 per cent
Medium: >50-<80 per cent
High: >80 per cent
2.5. Can PWHIV disclose their use of cocaine, crack, ATS or other substances to their medical provider without compromising their access to ART?
Yes/No
2.6. Is ART available as a part of combination prevention to people who use cocaine, crack or ATS regardless of their sero-status?
Yes/No
Potential impact indicators
2.7. Decreased AIDS cases and AIDS-related mortality among people who use stimulants
Data source:
Indicator:
HIV/AIDS register data
(a) Number of AIDS cases among HIV-infected people who use stimulants
(b) Number of AIDS-related deaths among people who use stimulants
2
.8. Reduction in the prevalence of HIV among people who use stimulants
Data source: HIV sentinel surveillance among people who use stimulants
Numerator:
Denominator:
Number of people who use stimulants in the sample testing positive for HIV
Number of people who use stimulants in the sample
4. Condom programmes for people who use stimulants and their sexual partners
156 World Health Organization, Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach — 2010 Revision (Geneva, 2010). Available from http://whqlibdoc.who.int/publications/2010/9789241599764_eng.pdf
29
Availability
4.1. Are there condom programmes targeting people who use stimulants and their sexual partners?
Yes/No
4.2. Condom programme outlets per 1,000 people who use stimulants
Data source:
Numerator:
Programme data
Number of condom programme sites
Denominator:
Target:
(Number of people who use stimulants)/1,000
Context-specific (should consider geographical distribution of the target population and other local factors influencing accessibility)
Condom programme outlets include those where condoms are available free of charge. Comment:
Coverage
4.3. Free condoms distributed each year per stimulant user
Data source:
Numerator:
Denominator:
Targets:
Programme data
Number of free condoms distributed in the previous 12 months
Number of people who use stimulants
Low: <50 per cent
Medium: >50-<100 per cent
High: >100 per cent
Quality
4.4. Percentage of condom programme distribution sites adhering to United Nation s Population Fund
(UNFPA) guidelines [144]
Data source:
Numerator:
Denominator:
Targets:
Programme data
Number of condom programme sites adhering to UNFPA guidelines
Number of sexually transmitted infection (STI) intervention sites
Low: <50 per cent
157
Medium: >50-<80 per cent
High: >80 per cent
Potential impact indicators
4.5. Increase in the percentage of people who use stimulants reporting the use of a condom the last time they had sexual intercourse
Data source:
Numerator:
Denominator:
Behavioural surveillance surveys
Number of respondents who reported that a condom was used the last time they had sexual intercourse
Number of respondents who reported having had sexual intercourse in the previous month
157 United Nations Population Fund, Condom Programming for HIV Prevention. An Operations Manual for Programme Managers (New York, 2005). Available from www.unfpa.org/webdav/site/global/shared/documents/publications/2005/condom_prog2.pdf
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4.6. Decrease in the number of STIs
Data source:
Numerator:
Programme data
Number of people who use stimulants diagnosed with an STI in the previous 12 months
Denominator:
Alternatively :
Data source:
Numerator:
Number of people who use stimulants tested for STIs in the previous 12 months
Behavioural surveillance surveys
Number of people who use stimulants who self-reported symptoms of an STI in the previous 12 months
Denominator: Number of participants who reported having had sexual intercourse in the previous 12 months
4.7. Decrease in the prevalence of HIV in people who use stimulants
Data source:
Numerator:
Denominator:
HIV sentinel surveillance among people who use stimulants
Number of people who use stimulants with HIV in the sample
Number of people who use stimulants in the sample
5. Needle and syringe programmes for people who inject stimulants
Needle and syringe programmes address the needs of injecting people who use stimulants as well as noninjecting people who use stimulants who are injecting users of other drugs such as opoids (e.g.
“speedballing”).
Availability
5.1. Do needle and syringe programmes (including pharmacy sites providing no -cost needles and syringes) exist?
Yes/No
5.2. Are needles and syringes available for sale in pharmacies without a prescription?
Yes/No
5.3. Needle and syringe programme sites (including pharmacy sites providing no -cost needles and syringes) per 1,000 people who use stimulants
Data source:
Numerator:
Programme data
Number of needle and syringe programme sites (including pharmacy s ites providing nocost needles and syringes)
(Number of people who use stimulants)/1,000 Denominator:
Target: Context-specific (should consider geographical distribution of the target population and other local factors influencing accessibility)
5.4. Pharmacy sales sites per 1,000 people who use stimulants
Data source:
Numerator:
Programme data
Number of pharmacy sites selling syringes
31
Denominator:
Target:
(Number of people who use stimulants)/1,000
Context-specific (should consider geographical distribution of the target population and other local factors influencing accessibility)
Coverage
Three coverage indicators are presented. The availability of data may dictate which of these indicators can be measured.
5.5. Percentage of people who use stimulants regularly reached by needle and syringe programmes
Data source:
Numerator:
Programme data
Number of people who use stimulants who accessed a needle and syringe programme once per month or more in the previous 12 months
Denominator:
Targets:
Number of people who use stimulants
Low: <20 per cent
Medium: >20-<60 per cent
High: >60 per cent
Comment: The numerator should count individual clients and not the number of contacts or occasions of service recorded by needle and syringe programme services. The high target level is based on a retrospective analysis of the coverage required to reverse the HIV/AIDS epidemic among people who use stimulants in New York.
5.6. Percentage of people who use stimulants reached by needle and syringe programmes in the previous month
Data source:
Numerator:
Programme data
Number of people who use stimulants who accessed a needle and syringe programme in the previous month
Denominator:
Targets:
Number of people who use stimulants
Low: <20 per cent
Medium: >20-<60 per cent
High: >60 per cent
Comment: The numerator should count individual clients and not the number of contacts or occasions of service recorded by needle and syringe programme services.
5.7. Needles and syringes distributed per stimulant user p er year
Data source:
Numerator:
Programme data
Number of needles and syringes distributed in the previous 12 months
Denominator:
Targets:
Number of people who use stimulants
Low: <100 per stimulant user per year
Medium: >100-<200
High: >200
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Comment: These levels are based upon studies in developed country settings investigating the levels of syringe distribution and impact on HIV transmission. Note that the levels required for the prevention of hepatitis C are likely to be much higher than those pre sented here. In most cases, only data on the number of syringes distributed via needle and syringe programmes (i.e. not pharmacy sales) will be available.
Quality
5.8. Percentage of needle and syringe programme sites adhering to current WHO, UNODC and UNAIDS guidelines on needle and syringe programmes
Data source:
Numerator:
Denominator:
Targets:
Programme data
Number of needle and syringe programme sites adhering to guidelines
Number of needle and syringe programme sites
Low: <50 per cent
Medium: >50-<80 per cent
High: >80 per cent
5.9. Percentage of needle and syringe programme sites adhering to UNAIDS best practice recommendations for HIV prevention
158
Data source:
Numerator:
Programme data
Number of needle and syringe programme sites adhering to UNAIDS best practice guidelines
Denominator:
Targets:
Number of needle and syringe programme sites
Low: <50 per cent
Medium: >50-<80 per cent
High: >80 per cent
5.10. Percentage of occasions when clients access a needle and syringe programme and r eceive information, education and communication
Data source:
Numerator:
Programme data
Number of occasions when clients access a needle and syringe programme and receive information, education and communication (i.e. the number of client contact events a t a needle and syringe programme that involve the client receiving information, education and communication)
Denominator:
Targets:
Total number of needle and syringe programme occasions of service
Low: <20 per cent
Medium: >20-<40 per cent
High: >40 per cent
5.11. Percentage of occasions when clients access a needle and syringe programme and receive condoms
Data source: Programme data
158 Joint United Nations Programme on HIV/AIDS, High Coverage Sites: HIV Prevention among Injecting Drug Users in Transitional and Developing Countries — Case Studies (Geneva, 2006).
Available from http://data.unaids.org/publications/IRC-pub07/jc1254-highcoverageidu_en.pdf
33
Numerator:
Denominator:
Targets:
Number of occasions when clients access a needle and syringe programme and receive condoms (i.e. the number of client contact events of a needle and syringe programme that involve the client receiving condoms)
Total number of needle and syringe programme occasions of service
Low: <20 per cent
Medium: >20-<40 per cent
High: >40 per cent
5.12. Percentage of occasions when clients access a needle and syringe programme and receive safer drug paraphernalia
Data source:
Numerator:
Programme data
Number of occasions when clients access a needle and syringe programme and receive safer drug paraphernalia (i.e. the number of client contact events of a needle and syringe programme that involve the client receiving safer drug paraphernalia)
Denominator:
Targets:
Total number of needle and syringe programme occasions of service
Low: <20 per cent
Medium: >20-<40 per cent
High: >40 per cent
Potential impact indicators
5.13. Increase in percentage of people who inject stimulants, or any other drugs, reporting the use of sterile injecting equipment the last time they injected
Data source:
Numerator:
Denominator:
Behavioural surveillance surveys (e.g. Family Health International behavioural surveillance surveys for people who inject drugs)
Number of respondents reporting the use of sterile injecting equipment the last time they injected drugs
Number of respondents who report having injected during the previous month
5.14. Increase in percentage of people who use stimulants who inject stimulants, or any other drugs, reporting the use of condoms in their most recent sexual encounter under the influ ence of stimulants
Data source:
Numerator:
Denominator:
Behavioural surveillance surveys (e.g. Family Health International behavioural surveillance surveys for people who inject drugs).
Number of respondents reporting the use of condoms during their most recent sexu al encounter under the influence of stimulants
Number of respondents who report having injected in the previous month
Indicator 5.15. Reduction in prevalence of HIV among people who use stimulants who inject stimulants or any drugs
Data source:
Numerator:
Denominator:
HIV sentinel surveillance among people who use stimulants
Number of people who use stimulants with HIV in sample
Number of people who use stimulants in sample who report having injected in the previous month
6. Behavioural interventions aimed at reducing HIV transmission risks
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Availability
6.1. Are there programmes offering behavioural interventions aimed at reducing HIV transmission risks for people who use stimulants?
Yes/No
6.2. Behavioural intervention programme sites per 1,000 people who use stimulants
Data source:
Numerator:
Programme data
Number of behavioural intervention programme sites
Denominator:
Target:
(Number of people who use stimulants)/1,000
Context-specific (should consider geographical distribution of the target population and other local factors influencing accessibility as well as populations at risk in the target population, such as men who have sex with men, or sex workers)
Coverage
6.3. Ratio of people who use stimulants receiving behavioural interventions
Data source:
Numerator:
Programme data
Number of people who use stimulants receiving behavioural interventions at census date
Denominator:
Targets:
Number of people who use stimulants
Low: <0.1
Medium: >0.1-<0.3
High: >0.3
Quality
6.4. Percentage of behavioural intervention programmes using methods based on evidence -based behavioural interventions
Data source:
Numerator:
Denominator:
Targets:
Number of behaviour intervention programmes
Low:
50 per cent
Medium: >50-
80 per cent
High: >80 per cent
Potential impact indicators
6.5. Increase in the percentage of people who use stimulants reporting the use of a condom the last ti me they had sexual intercourse
Data source:
Numerator:
Denominator:
Programme data
Number of behavioural intervention programmes using methods based on evidence -based treatments
Behavioural surveillance surveys
Number of respondents who report that a condom was used the last time they had sexual intercourse
Number of respondents who report having had sexual intercourse in the previous month
35
6.6. Increase in percentage of people who use stimulants reporting the use of condoms in their most recent sexual encounter under the influence of stimulants
Data source:
Numerator:
Behavioural surveillance surveys
Number of respondents reporting the use of condoms during their most recent sexual encounter under the influence of stimulants
Denominator: Number of respondents who report having injected in the previous month
6.7. Decrease in the number of STIs among people who use stimulants in behavioural intervention programmes
Data source:
Numerator:
Programme data
Number of people who use stimulants diagnosed with an STI in the previous 12 months
Number of people who use stimulants tested for STIs in the previous 12 months Denominator:
Alternatively :
Data source:
Numerator:
Behavioural surveillance surveys
Number of people who use stimulants who have self-reported symptoms of an STI in the previous 12 months
Denominator: Number of participants who report having ha d sexual intercourse in the previous 12 months
6.9. Decrease in the prevalence of HIV in people who use stimulants
Data source:
Numerator:
HIV sentinel surveillance among people who use stimulants
Number of people who use stimulants with HIV in sample
Denominator: Number of people who use stimulants in sample
7. Prevention and treatment of sexually transmitted infections, tuberculosis and viral hepatitis
Sexual health services for people who use stimulants may be provided by organizations or services that offer a number of services to people who use stimulants or by mainstream sexual health services that can be accessed by people who use stimulants . It may be difficult to gather data on access by people who use stimulants to mainstream sexual health services, as these services may not collect data on the status of stimulant drug use among their clients.
Availability
7.1. Are there sites offering STI screening and treatment for people who use stimulants?
Yes/No
7.2. STI intervention sites per 1,000 people who use stimulants
Data source:
Numerator:
Denominator:
Target:
Programme data
Number of sites offering STI screening and treatment to people who use stimulants
(Number of people who use stimulants)/1,000
Context-specific (should consider geographical distribution of the target population and other local factors influencing accessibility)
Coverage
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7.3. Percentage of people who use stimulants screened for STIs in the previous 12 months
Data source:
Numerator:
Programme data
Number of people who use stimulants screened in the previous 12 months
Denominator:
Alternatively :
Data source:
Number of people who use stimulants
Numerator:
Denominator:
Targets:
Behavioural surveillance surveys with questions on exposure to interventions
Number of people who use stimulants screened in the previous 12 months
Number of people who use stimulants in sample
Low: <20 per cent
Medium: >20-<50 per cent
High: >50 per cent
Quality
7.4. Percentage of sites adhering to WHO guidelines on STI screening a nd treatment [147]
Data source:
Numerator:
Denominator:
Targets:
Programme data
Number of STI intervention sites adhering to WHO guidelines [147]
Number of STI intervention sites
Low: <50 per cent
Medium: >50-<80 per cent
High: >80 per cent
7.5. Percentage of people who use stimulants diagnosed with STI who receive treatment
Data source:
Numerator:
Programme data
Number of people who use stimulants who have received STI treatment in the previous 12 months
Denominator:
Targets:
Number of people who use stimulants diagnosed with an STI in the previous 12 months
Low: <50 per cent
Medium: >50-<80 per cent
High: >80 per cent
Potential impact indicators
7.6. Decrease in the number of STIs among people who use stimulants
Data source:
Numerator:
Denominator:
Alternatively :
Data source:
Programme data
Number of people who use stimulants diagnosed with an STI in the previous 12 months
Number of people who use stimulants tested for STIs in the previous 12 months
Behavioural surveillance surveys
37
Numerator: Number of people who use stimulants who have self-reported symptoms of an STI in the previous 12 months
Number of participants who report having had sexual intercourse in the previous 12 months Denominator:
8. Targeted information, education and communication programmes about stimulant use and HIV
Availability
8.1. Are targeted information, education and communication programmes available for people who use stimulants?
Yes/No
8.2. Number of sites offering targeted information, education an d communication programmes for people who use stimulants per 1,000 people who use stimulants
Data source:
Numerator:
Programme data
Number of sites offering targeted information, education and communication programmes to people who use stimulants
(Number of people who use stimulants)/1,000 Denominator:
8.3. Number of targeted materials on stimulant use distributed per stimulant user per year
Data source:
Numerator:
Programme data
Number of targeted materials on people who use stimulants and HIV distributed in the previous 12 months
Denominator: Number of people who use stimulants
Coverage
8.4. Percentage of people who use stimulants reached by information, education and communication programmes
Data source:
Numerator:
Programme data
Number of people who use stimulants who have received information, education and communication in the previous 12 months
Denominator:
Targets:
Number of people who use stimulants
Low: <50 per cent
Medium: >50-<80 per cent
High: >80 per cent
Quality
8.5. Percentage of information, education and communication materials that were developed with direct input from people who use stimulant drugs
Data source:
Numerator:
Denominator:
Programme data
Types of information, education and communication materials that were developed with direct input from people who use stimulant drugs
Types of information, education and communication materials for people who use stimulant drugs
38
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Targets: Low: <50 per cent
Medium: >50-<80 per cent
High: >80 per cent
Potential impact indicators
Indicator 8.6. Increase in the use of condoms among people who use stimulants
Data source:
Numerator:
Denominator:
Behavioural surveillance surveys
Number of respondents reporting the use of condoms during their most recent sexual encounter under the influence of stimulants
Number of people who use stimulants
39
